Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 10492-024 | WI |
NPI | 1003073016 |
---|---|
Provider Name | Dr. Michael A Teller |
First Address | Brown Deer, WI 53223-2400 |
Second Address | Brown Deer, WI 53223-2400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2008 |
Last Update Date | 19/05/2008 |