Healthcare Provider Details

I. General information

NPI: 1912129735
Provider Name (Legal Business Name): DR ELTON X TINSLEY & ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N MICHIGAN AVE SUITE 957W
CHICAGO IL
60611-2252
US

IV. Provider business mailing address

PO BOX 804193
CHICAGO IL
60680-4103
US

V. Phone/Fax

Practice location:
  • Phone: 312-222-0030
  • Fax: 312-649-5808
Mailing address:
  • Phone: 312-222-0030
  • Fax: 312-649-5808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number36079325
License Number StateIL

VIII. Authorized Official

Name: DR. ELTON XAVIER TINSLEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-222-0030