Provider Demographics
NPI:1073582110
Name:TEAGUE, TODD (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:TEAGUE
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 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-423-8697
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:2863 HIGHWAY 45 BYP
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3618
Practice Address - Country:US
Practice Address - Phone:731-664-1375
Practice Address - Fax:731-660-2558
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD28190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3802728Medicaid
TN3802728Medicaid
TN3802727Medicare PIN
G28850Medicare UPIN