Basic Information
| Provider Information | |||||||||
| NPI: | 1023325362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEICHMAN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | G | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2859 STATE ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412826500 | ||||||||
| FaxNumber: | 5412826520 | ||||||||
| Practice Location | |||||||||
| Address1: | 2859 STATE ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412826500 | ||||||||
| FaxNumber: | 5412826520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2010 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19719 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 180720 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500719117 | 05 | OR | MEDICAID |