Provider Demographics
NPI:1811941446
Name:TEAL, THOMAS M (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:TEAL
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 1:826 W KING ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2120
Mailing Address - Country:US
Mailing Address - Phone:989-723-5211
Mailing Address - Fax:
Practice Address - Street 1:826 W KING ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2120
Practice Address - Country:US
Practice Address - Phone:989-723-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104426400Medicaid
MIE37200Medicare UPIN
MIN53550014Medicare ID - Type Unspecified