Provider Demographics
NPI:1619985579
Name:TERRY, BILL TAYLOR (MD)
Entity type:Individual
Prefix:DR
First Name:BILL
Middle Name:TAYLOR
Last Name:TERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:TAYLOR
Other - Last Name:TERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 44450
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-0450
Mailing Address - Country:US
Mailing Address - Phone:208-322-1001
Mailing Address - Fax:208-939-8801
Practice Address - Street 1:408 22ND AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5424
Practice Address - Country:US
Practice Address - Phone:208-866-5365
Practice Address - Fax:208-939-8801
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-55942084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002034500Medicaid
ID1122849Medicare ID - Type Unspecified