Provider Demographics
NPI:1982683975
Name:TEGTMEIER, TERRENCE E (MD)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:E
Last Name:TEGTMEIER
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 1:2600 6TH ST SW
Mailing Address - Street 2:SUITE A2-710
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1702
Mailing Address - Country:US
Mailing Address - Phone:330-454-8076
Mailing Address - Fax:330-454-3927
Practice Address - Street 1:2600 6TH ST SW
Practice Address - Street 2:SUITE A2-710
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-454-8076
Practice Address - Fax:330-454-3927
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-6140207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0465723Medicaid
OH0465723Medicaid
OHA80020Medicare UPIN