Provider Demographics
NPI:1902869696
Name:LEVENSON, TERRY B (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:B
Last Name:LEVENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2180
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-2180
Mailing Address - Country:US
Mailing Address - Phone:843-347-7216
Mailing Address - Fax:843-234-6990
Practice Address - Street 1:8004 MYRTLE TRACE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8945
Practice Address - Country:US
Practice Address - Phone:843-347-7216
Practice Address - Fax:843-347-7218
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC09347207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC6427Medicaid
SC093473Medicaid
SC621213OtherFIRST CHOICE IDENTIFIER
SC7844Medicare PIN
SC621213OtherFIRST CHOICE IDENTIFIER