=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609863422
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRIAM B TEDDER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2005
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525A DEVONIA ST
-----------------------------------------------------
City | HARRIMAN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37748-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-882-5701
-----------------------------------------------------
Fax | 865-882-2568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 525A DEVONIA ST
-----------------------------------------------------
City | HARRIMAN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37748-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-882-5701
-----------------------------------------------------
Fax | 865-882-2568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD10022
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------