Provider Demographics
NPI:1538129333
Name:TEDRICK, PHILLIP D (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:TEDRICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5717
Mailing Address - Country:US
Mailing Address - Phone:207-626-1303
Mailing Address - Fax:
Practice Address - Street 1:6 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5717
Practice Address - Country:US
Practice Address - Phone:207-626-1303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1498207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME930047481Medicare PIN
MEC44817Medicare UPIN
MEMM6155Medicare PIN