Healthcare Provider Details

I. General information

NPI: 1619922457
Provider Name (Legal Business Name): MICHAEL D TEAGUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 E LAMAR ALEXANDER PARKWAY
MARYVILLE TN
37804-5012
US

IV. Provider business mailing address

PO BOX 51883
KNOXVILLE TN
37950-1883
US

V. Phone/Fax

Practice location:
  • Phone: 865-981-2335
  • Fax: 865-694-4339
Mailing address:
  • Phone: 865-766-8897
  • Fax: 865-766-8874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number21749
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number21749
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: