Provider Demographics
NPI:1700930914
Name:TEDESCO, ELEANOR THERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELEANOR
Middle Name:THERESA
Last Name:TEDESCO
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 1:3922 GLENMERE DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6769
Mailing Address - Country:US
Mailing Address - Phone:508-769-2364
Mailing Address - Fax:843-668-2468
Practice Address - Street 1:3922 GLENMERE DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6769
Practice Address - Country:US
Practice Address - Phone:508-769-2364
Practice Address - Fax:843-668-2468
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1522832084P0800X
SC873982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3178111Medicaid
MAA23376Medicare ID - Type Unspecified
MAG64754Medicare UPIN