Provider Demographics
NPI:1407842321
Name:NEGELE, TRISTA (MD)
Entity Type:Individual
Prefix:DR
First Name:TRISTA
Middle Name:
Last Name:NEGELE
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 1:800 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 2004
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:874-952-7375
Mailing Address - Fax:
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 2004
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-952-7375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092361208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633552OtherBCBS PROVIDER ID
IL1633552OtherBCBS PROVIDER ID
ILH57390Medicare UPIN
ILP00195636Medicare ID - Type UnspecifiedRR MEDICARE