Basic Information
| Provider Information | |||||||||
| NPI: | 1962630111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEAGARDEN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 ARCH ST | ||||||||
| Address2: | SUITE 3A | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753584 | ||||||||
| FaxNumber: | 3303753730 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 ARCH ST | ||||||||
| Address2: | SUITE 3A | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753584 | ||||||||
| FaxNumber: | 3303753730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 03/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34.011247 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12379835 | 01 | MI | CAQH UNIVERSAL PROVIDER ID | OTHER |