Healthcare Provider Details

I. General information

NPI: 1942906276
Provider Name (Legal Business Name): HEIDI TEDDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 CARLYLE AVE
BELLEVILLE IL
62221-6223
US

IV. Provider business mailing address

515 CARLYLE AVE
BELLEVILLE IL
62221-6223
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-1827
  • Fax:
Mailing address:
  • Phone: 618-222-1827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049239806
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: