Healthcare Provider Details

I. General information

NPI: 1871334748
Provider Name (Legal Business Name): SYLVANUS TEKWECK TEBOH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 23RD AVE S STE 200
FARGO ND
58104-9138
US

IV. Provider business mailing address

4820 23RD AVE S STE 200
FARGO ND
58104-9138
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-4113
  • Fax: 701-293-4109
Mailing address:
  • Phone: 701-293-4113
  • Fax: 701-293-4109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberRL21157
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: