Provider Demographics
NPI: | 1851617120 |
---|---|
Name: | KERGE, TERESA MARIE (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | TERESA |
Middle Name: | MARIE |
Last Name: | KERGE |
Suffix: | |
Gender: | F |
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: | 3310 FALL HILL AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | FREDERICKSBURG |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 22401-3000 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 540-373-4602 |
Mailing Address - Fax: | 540-373-5461 |
Practice Address - Street 1: | 2549 COWAN BLVD |
Practice Address - Street 2: | |
Practice Address - City: | FREDERICKSBURG |
Practice Address - State: | VA |
Practice Address - Zip Code: | 22401-8440 |
Practice Address - Country: | US |
Practice Address - Phone: | 540-368-3970 |
Practice Address - Fax: | 540-368-3973 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2010-04-12 |
Last Update Date: | 2023-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0101259196 | 208VP0014X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
C09813 | Other | MEDICARE GROUP PTAN | |
1457308611 | Other | MEDICARE GROUP NPI | |
VA | 0101259196 | Other | MEDICAL LICENSE |
1851617120 | Other | NPI | |
FK5650230 | Other | DEA |