Provider Demographics
NPI:1487836284
Name:TLC MEDICAL GROUP, S.C.
Entity Type:Organization
Organization Name:TLC MEDICAL GROUP, S.C.
Other - Org Name:TLC WOMEN'S HEALTH S.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-513-9160
Mailing Address - Street 1:40W222 LA FOX ROAD
Mailing Address - Street 2:SUITE J1
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175
Mailing Address - Country:US
Mailing Address - Phone:630-513-9160
Mailing Address - Fax:630-513-9617
Practice Address - Street 1:40W222 LA FOX ROAD
Practice Address - Street 2:SUITE J1
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175
Practice Address - Country:US
Practice Address - Phone:630-513-9160
Practice Address - Fax:630-513-9617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03106052207VG0400X
IL036104024208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1851452775OtherNPI NUMBER
IL4532123OtherBLUECROSS BLUE SHIELD
IL4532123OtherBLUECROSS BLUE SHIELD