Provider Demographics
NPI:1427677053
Name:TEAL, BENNETT HASKIN (MD)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:HASKIN
Last Name:TEAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BENNETT
Other - Middle Name:LEANNA
Other - Last Name:HASKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTENTION PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:1301 CREEL ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29527-5018
Practice Address - Country:US
Practice Address - Phone:843-248-4414
Practice Address - Fax:843-248-3781
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC84208207Q00000X
SCLL84208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC842084Medicaid