Provider Demographics
NPI:1871561779
Name:TEAHAN, MARY E (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:TEAHAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-0391
Mailing Address - Country:US
Mailing Address - Phone:270-781-0028
Mailing Address - Fax:270-781-0007
Practice Address - Street 1:1600 SCOTTSVILLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3217
Practice Address - Country:US
Practice Address - Phone:270-781-0028
Practice Address - Fax:270-781-0007
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1218941OtherCHA HEALTH
KY000000375307OtherANTHEM BC/BS
KY87001939Medicaid
KYP00307093Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KY87001939Medicaid