Provider Demographics
NPI:1851326888
Name:TEAGUE, CLINT (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 CLINTON CENTER DR STE 4300
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5610
Mailing Address - Country:US
Mailing Address - Phone:888-815-2005
Mailing Address - Fax:601-815-0434
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:604-984-1000
Practice Address - Fax:601-815-0434
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS174732085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05426331Medicaid
TN1526782Medicaid
MSP00271111OtherRAILROAD MEDICARE
MSP00462329OtherRAILROAD MEDICARE
MS512G700003OtherMS MEDICARE - GROUP
MSP00462329OtherRAILROAD MEDICARE
MS3000001020Medicare ID - Type Unspecified