Provider Demographics
NPI:1104894906
Name:LYNCH, TERESA (MD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3172
Mailing Address - Country:US
Mailing Address - Phone:309-624-9690
Mailing Address - Fax:309-624-9723
Practice Address - Street 1:320 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3172
Practice Address - Country:US
Practice Address - Phone:309-624-9690
Practice Address - Fax:309-624-9723
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111072208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP PTAN
IL036111072Medicaid
ILK16399Medicare ID - Type Unspecified
IL036111072Medicaid
IL809840OtherMEDICARE GROUP PTAN