MEDICARE: DR. STEWART EDWARD TEAL M.D.

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	2084P0804X	Child & Adolescent Psychiatry Physician	C30919	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	005583-000	OTHER	CA	MAGELLAN

General Provider Information

NPI Number	:	1902809460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEWART EDWARD TEAL M.D.

Provider Business Mailing Address
First Line	:	811 GRAND AVE STE D
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95838-3466
Country	:	US
Telephone Number	:	916-922-9868
Fax Number	:	916-922-7342

Provider Business Practice Location Address
First Line	:	811 GRAND AVE STE D
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95838-3466
Country	:	US
Telephone Number	:	916-922-9868
Fax Number	:	916-922-7342

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	09/27/2013

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