MEDICARE: MR. TROY TEAGARDIN PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	5601004173	MI

General Provider Information

NPI Number	:	1619969243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TROY TEAGARDIN PAC

Provider Business Mailing Address
First Line	:	2500 NILES RD STE 6
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-3268
Country	:	US
Telephone Number	:	269-408-1660
Fax Number	:	269-408-1665

Provider Business Practice Location Address
First Line	:	2500 NILES RD STE 6
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-3268
Country	:	US
Telephone Number	:	269-408-1660
Fax Number	:	269-408-1665

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	10/15/2012

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Directions to “ MR. TROY TEAGARDIN PAC” Practice Location

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