Provider Demographics
NPI:1073990958
Name:TEDESCO MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:TEDESCO MEDICAL ASSOCIATES, LLC
Other - Org Name:E THERESA TEDESCO MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:TEDESCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-762-4105
Mailing Address - Street 1:19 WHEELOCK RD
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-1834
Mailing Address - Country:US
Mailing Address - Phone:508-845-6510
Mailing Address - Fax:508-845-6512
Practice Address - Street 1:131 LINCOLN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2408
Practice Address - Country:US
Practice Address - Phone:508-762-4105
Practice Address - Fax:508-762-4106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1522832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3178111Medicaid
MA3178111Medicaid