MEDICARE: DR. MAE ELLEN TERREBONNE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	0101054314	VA

General Provider Information

NPI Number	:	1619055936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAE ELLEN TERREBONNE M.D.

Provider Business Mailing Address
First Line	:	18314 GENERAL PULLER HWY
Second Line	:
City	:	DELTAVILLE
State	:	VA
Zip	:	23043-2029
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2221 EDWARD HOLLAND DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-2518
Country	:	US
Telephone Number	:	804-354-2140
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	07/08/2007

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