Healthcare Provider Details

I. General information

NPI: 1851699029
Provider Name (Legal Business Name): TEETER PEDIATRIC CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 WISCONSIN AVE
JOPLIN MO
64804-2873
US

IV. Provider business mailing address

3126 WISCONSIN AVE
JOPLIN MO
64804-2873
US

V. Phone/Fax

Practice location:
  • Phone: 417-437-0242
  • Fax:
Mailing address:
  • Phone: 417-437-0242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2005013271
License Number StateMO

VIII. Authorized Official

Name: DR. RAYNI L TEETER
Title or Position: OWNER
Credential: M.D.
Phone: 417-437-0242