Individual
THENA GIDGET POTEAT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
6805 STATE ROUTE 162 STE 201, MARYVILLE, IL 62062-8530
(618) 288-5189
Mailing address
6805 IL 162, SUITE 201, MARYVILLE, IL 62062-4181
(618) 288-5189
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
03611132
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036111132
—
IL
Enumeration date
06/01/2006
Last updated
03/19/2024
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