Provider Demographics
NPI:1104923218
Name:HARRELL, TERESA J (MD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:J
Last Name:HARRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:J
Other - Last Name:TROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:420 W COLLEGE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-1250
Mailing Address - Country:US
Mailing Address - Phone:417-633-7020
Mailing Address - Fax:417-633-7024
Practice Address - Street 1:420 W COLLEGE ST STE 100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1250
Practice Address - Country:US
Practice Address - Phone:417-633-7020
Practice Address - Fax:417-633-7024
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
114251OtherBLUE CROSS OF MO
MO209784503Medicaid
114251OtherBLUE CROSS OF MO
MO209784503Medicaid
963105121Medicare PIN
G38191Medicare UPIN
P00371909Medicare PIN