MEDICARE: MS. TERESA SUZANNE HARLESS

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1548303258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERESA SUZANNE HARLESS

Provider Business Mailing Address
First Line	:	1024 RIVERMET AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4231
Country	:	US
Telephone Number	:	260-426-2118
Fax Number	:	260-426-2118

Provider Business Practice Location Address
First Line	:	1024 RIVERMET AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4231
Country	:	US
Telephone Number	:	260-426-2118
Fax Number	:	260-426-2118

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

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	07/09/2007

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