Provider Demographics
NPI:1710071832
Name:TJELMELAND PLASTIC SURGERY, P. A.
Entity Type:Organization
Organization Name:TJELMELAND PLASTIC SURGERY, P. A.
Other - Org Name:KELLY E. TJELMELAND M. D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:TJELMELAND
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:512-617-7500
Mailing Address - Street 1:4220 BULL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4220 BULL CREEK RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6026
Practice Address - Country:US
Practice Address - Phone:512-617-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7860208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169603101Medicaid
TX8AQ830OtherBCBS INDIVIDUAL NUMBER
TX169603101Medicaid