Courtney L Teller, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

085004426 Issued in IL

Practice address

102 S Hennepin Ave
Dixon, IL 61021-3013

Phone

(815) 285-8523

Fax

(815) 285-8901

NPI assigned

Sep 28, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• KSB Medical Group, Inc.

  • Family Medicine Physician
  • Dixon, IL
  • NPI 1073592119
  Medicare reassignment NPD
• KSB Medical Group, Inc.

  dba KSB Optical

  • Eyewear Supplier
  • Dixon, IL
  • NPI 1306814603
  NPD
• Office of County Treasurer

  dba Lee County Treasurer

  • Public Health or Welfare Agency
  • Dixon, IL
  • NPI 1487648234
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1348790400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1535328000000",
    "number": "1417208505",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "102 S HENNEPIN AVE",
            "city": "DIXON",
            "state": "IL",
            "postal_code": "610213013",
            "telephone_number": "815-285-8523",
            "fax_number": "815-285-8901"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "102 S HENNEPIN AVE",
            "city": "DIXON",
            "state": "IL",
            "postal_code": "610213013",
            "telephone_number": "815-285-8523",
            "fax_number": "815-285-8901"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "215 E 1st St Ste 215",
            "address_purpose": "LOCATION",
            "city": "Dixon",
            "state": "IL",
            "postal_code": "610213166",
            "country_code": "US",
            "telephone_number": "815-285-5420",
            "fax_number": "815-285-5426",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TELLER",
        "first_name": "COURTNEY",
        "middle_name": "L",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-09-28",
        "last_updated": "2018-08-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085004426",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "381220033",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "329785745001",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kyle Swanson
• Kayla Sward
• Swedishamerican Hospital
• Mouhammad F Tarsha, M.D.
• Tyrone Tejam
• Leigh Terrell, LCPC
• Terri Ann Thibado, MHP
• Hilary Lizbeth Thomas
• Pamela Thomas, RBT
• Laura Thompson, MHP

• Physician Assistant in Dixon, IL
• Providers in Dixon, IL by specialty
• Physician Assistant in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 27, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.