Healthcare Provider Details

I. General information

NPI: 1568720142
Provider Name (Legal Business Name): TEAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 WEDDINGTON BRANCH RD STE C
PIKEVILLE KY
41501-3296
US

IV. Provider business mailing address

PO BOX 4150
PIKEVILLE KY
41502-4150
US

V. Phone/Fax

Practice location:
  • Phone: 606-437-2400
  • Fax: 606-437-2401
Mailing address:
  • Phone: 606-437-2400
  • Fax: 606-218-6082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02802
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number02802
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number03136
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number03117
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3009093
License Number StateKY
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE FORD
Title or Position: PARTNER/OWNER
Credential: D.O.
Phone: 606-437-2400