Healthcare Provider Details

I. General information

NPI: 1295135721
Provider Name (Legal Business Name): TLKM PLASTIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 N MICHIGAN AVE SUITE 1500
CHICAGO IL
60611-2615
US

IV. Provider business mailing address

737 N MICHIGAN AVE SUITE 1500
CHICAGO IL
60611-2615
US

V. Phone/Fax

Practice location:
  • Phone: 312-788-2560
  • Fax: 312-788-2563
Mailing address:
  • Phone: 312-788-2560
  • Fax: 312-788-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036082162
License Number StateIL

VIII. Authorized Official

Name: DR. THOMAS A. MUSTOE
Title or Position: SURGEON
Credential: M.D.
Phone: 312-788-2560