Provider Demographics
NPI:1790752723
Name:OSTASZEWSKI, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:OSTASZEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:586-498-2400
Mailing Address - Fax:586-498-2800
Practice Address - Street 1:25311 LITTLE MACK AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3301
Practice Address - Country:US
Practice Address - Phone:586-498-2400
Practice Address - Fax:586-498-2800
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1790752723Medicaid