MEDICARE: MARK D TEETER M.D.

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	207L00000X	Anesthesiology Physician	C7545	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376645317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK D TEETER M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2610
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72902-2610
Country	:	US
Telephone Number	:	479-785-2555
Fax Number	:	479-785-3555

Provider Business Practice Location Address
First Line	:	2910 JENNY LIND
Second Line	:	BLDG #12
City	:	FORT SMITH
State	:	AR
Zip	:	72901-6735
Country	:	US
Telephone Number	:	479-785-2555
Fax Number	:	479-785-3555

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

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	07/08/2007

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