Healthcare Provider Details

I. General information

NPI: 1578542668
Provider Name (Legal Business Name): SUSAN E TEGGATZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O SUITE 1
FORT MADISON IA
52627-9601
US

IV. Provider business mailing address

5409 AVENUE O SUITE 1
FORT MADISON IA
52627-9601
US

V. Phone/Fax

Practice location:
  • Phone: 319-376-2134
  • Fax: 319-376-2188
Mailing address:
  • Phone: 319-376-2134
  • Fax: 319-376-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33739
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1578542668
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK BLUE CROSS BLUE SHIELD
# 2
Identifier1578542668
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: