Provider Demographics
NPI:1467470138
Name:TEITELBAUM, MARY MARTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARTHA
Last Name:TEITELBAUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 NIGHTINGALE LN
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:VA
Mailing Address - Zip Code:24378-2475
Mailing Address - Country:US
Mailing Address - Phone:276-579-4818
Mailing Address - Fax:
Practice Address - Street 1:565 RADIO HILL RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-6587
Practice Address - Country:US
Practice Address - Phone:276-782-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840860363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA113138Medicare PIN
S43748Medicare UPIN