Healthcare Provider Details

I. General information

NPI: 1134458524
Provider Name (Legal Business Name): NOEL C TEODORO RSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

16525 W 159TH ST # 140
LOCKPORT IL
60441-7900
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone: 708-602-2183
  • Fax: 815-600-8637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000243
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number238.000243
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number238.000243
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: