Provider Demographics
NPI:1285680611
Name:EDWIN P TEEHAN MD PC
Entity Type:Organization
Organization Name:EDWIN P TEEHAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:TEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-720-8333
Mailing Address - Street 1:PO BOX 4015
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-0415
Mailing Address - Country:US
Mailing Address - Phone:973-720-8333
Mailing Address - Fax:973-720-0408
Practice Address - Street 1:510 HAMBURG TPKE
Practice Address - Street 2:SUITE 205
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2025
Practice Address - Country:US
Practice Address - Phone:973-720-8333
Practice Address - Fax:973-720-0408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA56236174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6947204Medicaid
NJ6947204Medicaid
NJG25210Medicare UPIN