Healthcare Provider Details

I. General information

NPI: 1023332038
Provider Name (Legal Business Name): TERESA M TIDD CST/CFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA M MCPHEETERS CST/CFA

II. Dates (important events)

Enumeration Date: 03/19/2010
Last Update Date: 03/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8433 HARCOURT RD SUITE 100
INDIANAPOLIS IN
46260-2190
US

IV. Provider business mailing address

8433 HARCOURT RD SUITE 100
INDIANAPOLIS IN
46260-2190
US

V. Phone/Fax

Practice location:
  • Phone: 317-583-7600
  • Fax: 317-583-7601
Mailing address:
  • Phone: 317-583-7600
  • Fax: 317-583-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: