Healthcare Provider Details

I. General information

NPI: 1174523625
Provider Name (Legal Business Name): TERI A MERENS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 HOWARD ST SUITE 203
EVANSTON IL
60202-3766
US

IV. Provider business mailing address

PO BOX 640
MATTESON IL
60443-0640
US

V. Phone/Fax

Practice location:
  • Phone: 847-869-4300
  • Fax: 847-869-4330
Mailing address:
  • Phone: 708-747-5850
  • Fax: 708-747-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036077183
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: