Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 8959 | SC |
N | 207QA0505X | Family Doctor - Adult Medicine | 8959 | SC |
NPI | 1164400214 |
---|---|
Provider Name | Dr. Ralph Athen Tesseneer III |
First Address | Atlanta, GA 30374-3070 |
Second Address | Spartanburg, SC 29307-1022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/01/2006 |
Last Update Date | 31/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
089594 | (05) | SC |
P00386809 | MEDICARE RAILROAD PTAN# (01) | GA |
SCE4905019 | MEDICARE PIN (01) | SC |