1427677053 NPI number — BENNETT HASKIN TEAL MD

Table of content: BENNETT HASKIN TEAL MD (NPI 1427677053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427677053 NPI number — BENNETT HASKIN TEAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEAL
Provider First Name:
BENNETT
Provider Middle Name:
HASKIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HASKIN
Provider Other First Name:
BENNETT
Provider Other Middle Name:
LEANNA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427677053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 SINGLETON RIDGE RD
Provider Second Line Business Mailing Address:
ATTENTION PNS CREDENTIALING
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29526-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-234-6946
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 CREEL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29527-5018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-248-4414
Provider Business Practice Location Address Fax Number:
843-248-3781
Provider Enumeration Date:
04/14/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  84208 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 842084 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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