Provider Demographics
NPI:1780602086
Name:TEAGUE, CARMEN I (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:I
Last Name:TEAGUE
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6842 CARNEGIE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3500
Practice Address - Country:US
Practice Address - Phone:980-270-4588
Practice Address - Fax:980-351-1277
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01319Medicaid
NC137A7OtherBCBS NC
NC89137A7Medicaid
NC1780602086Medicaid
I07468Medicare UPIN
NC2026934CMedicare PIN
NC2026934Medicare PIN
NC2026934BMedicare PIN