MEDICARE: TERESIA MCCOLLISTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	RN 268022	CA

General Provider Information

NPI Number	:	1336132166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESIA MCCOLLISTER

Provider Business Mailing Address
First Line	:	6000 N FIGUEROA ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90042-4232
Country	:	US
Telephone Number	:	323-254-5221
Fax Number	:	323-254-4618

Provider Business Practice Location Address
First Line	:	2411 N BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-2218
Country	:	US
Telephone Number	:	323-987-2000
Fax Number	:	323-987-1448

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	02/01/2012

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Directions to “ TERESIA MCCOLLISTER ” Practice Location

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