Healthcare Provider Details

I. General information

NPI: 1861400806
Provider Name (Legal Business Name): GREGORY SCOTT TERRELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 S BROADWAY AVE STE 200
TYLER TX
75703-3748
US

IV. Provider business mailing address

108 W CLARKSVILLE ST
JEFFERSON TX
75657-1818
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-6078
  • Fax:
Mailing address:
  • Phone: 806-420-7419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberK1695
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: