Basic Information
| Provider Information | |||||||||
| NPI: | 1346761947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBILAH | ||||||||
| FirstName: | TERNGU | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 SUN TEMPLE DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357588643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569754291 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1040 LONGFIELD CT | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361178055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562883333 | ||||||||
| FaxNumber: | 2562883334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2017 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BP10061363 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | 42769 | AL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.