Provider Demographics
NPI:1093928566
Name:FRASER, M. TERESA C (MD)
Entity Type:Individual
Prefix:DR
First Name:M.
Middle Name:TERESA C
Last Name:FRASER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 W. GARDEN STREET
Mailing Address - Street 2:HEARTLAND COMMUNITY HEALTH CLINIC
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-3531
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-676-5506
Practice Address - Street 1:1701 W. GARDEN STREET
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-3531
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-680-7637
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0888972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088897Medicaid
IL809840OtherMEDICARE GROUP #
IL809840OtherMEDICARE GROUP #