Provider Demographics
NPI:1639132079
Name:HARGRAVE, TERESA MENKE (MD, MPH, FAAP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MENKE
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:MD, MPH, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2017
Mailing Address - Country:US
Mailing Address - Phone:315-703-2800
Mailing Address - Fax:315-703-2885
Practice Address - Street 1:742 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2017
Practice Address - Country:US
Practice Address - Phone:315-703-2800
Practice Address - Fax:315-703-2885
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117677208000000X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01076113Medicaid
NYBB9426Medicare ID - Type Unspecified
NY01076113Medicaid