Healthcare Provider Details

I. General information

NPI: 1801876586
Provider Name (Legal Business Name): TIESENGA SURGICAL ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 N HARLEM AVE
ELMWOOD PARK IL
60707
US

IV. Provider business mailing address

1950 N HARLEM AVE
ELMWOOD PARK IL
60707
US

V. Phone/Fax

Practice location:
  • Phone: 708-453-6800
  • Fax: 708-453-3985
Mailing address:
  • Phone: 708-453-6800
  • Fax: 708-453-3985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number042000966
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number042000966
License Number StateIL

VIII. Authorized Official

Name: KATHLEEN BURDETT
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 708-453-6800