Provider Demographics
NPI:1174523625
Name:MERENS, TERI A (MD)
Entity type:Individual
Prefix:DR
First Name:TERI
Middle Name:A
Last Name:MERENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0640
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-7991
Practice Address - Street 1:1325 HOWARD ST
Practice Address - Street 2:SUITE 203
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3766
Practice Address - Country:US
Practice Address - Phone:847-869-4300
Practice Address - Fax:847-869-4330
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077183208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
361876926OtherEIN