Provider Demographics
NPI:1649334186
Name:TLC MEDICAL GROUP, S.C.
Entity type:Organization
Organization Name:TLC MEDICAL GROUP, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:IM
Authorized Official - Last Name:KAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-513-9160
Mailing Address - Street 1:2455 DEAN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-4830
Mailing Address - Country:US
Mailing Address - Phone:630-513-9160
Mailing Address - Fax:630-513-9617
Practice Address - Street 1:2455 DEAN ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-4830
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:2006-12-20
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106052207V00000X
IL036121171208000000X
IL036104024208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36104024Medicaid
IL4532123OtherBCBS
IL207006Medicare PIN