Healthcare Provider Details

I. General information

NPI: 1508968934
Provider Name (Legal Business Name): MICHAEL JOSEPH TEBALT III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 MEMORIAL DR
SENECA SC
29672-9443
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-885-7532
  • Fax:
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25822
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: