=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073990958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEDESCO MEDICAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2015
-----------------------------------------------------
Last Update Date | 04/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 LINCOLN ST SUITE 8
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605-2408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-762-4105
-----------------------------------------------------
Fax | 508-762-4106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 WHEELOCK RD
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01545-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-845-6510
-----------------------------------------------------
Fax | 508-845-6512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELEANOR THERESA TEDESCO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 508-762-4105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 152283
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------