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1750486445

NPI Code Detail

MEDICARE: TERESA J TIBBETTS MD

MEDICARE: TERESA J TIBBETTS MD

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	27163	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z102474	OTHER	AZ	MEDICARE INDIVIDUAL PTAN
3	DD0854	OTHER	AZ	RAILROAD MEDICARE GROUP #
6	Z102475	OTHER	AZ	MEDICARE GROUP PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	2Z2286	OTHER	AZ	HEALTH NET PROVIDER #

General Provider Information

NPI Number	:	1750486445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA J TIBBETTS MD

Provider Business Mailing Address
First Line	:	PO BOX 2325
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-2325
Country	:	US
Telephone Number	:	928-680-4233
Fax Number	:	928-680-6522

Provider Business Practice Location Address
First Line	:	2082 MESQUITE AVE
Second Line	:	SUITE 106
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6710
Country	:	US
Telephone Number	:	928-680-4233
Fax Number	:	928-680-6522

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	02/09/2016

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1124123765 — MICHAEL STEPHEN ROSEN MD
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1053594275 — TERESA J TIBBETTS M D LLC
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1366625584 — MICHAEL S ROSEN PC
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Directions to “ TERESA J TIBBETTS MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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