Healthcare Provider Details

I. General information

NPI: 1437371010
Provider Name (Legal Business Name): TEENA JOHN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 8TH ST PAV-3A158
SPRINGFIELD IL
62701-1041
US

IV. Provider business mailing address

PO BOX 9658
SPRINGFIELD IL
62794-9658
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8853
  • Fax: 217-545-0828
Mailing address:
  • Phone: 217-545-8853
  • Fax: 217-545-0828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125048464
License Number StateIL

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: