Healthcare Provider Details

I. General information

NPI: 1841295193
Provider Name (Legal Business Name): MEECHAI TESSALEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SALT CREEK LN
HINSDALE IL
60521-2990
US

IV. Provider business mailing address

900 S FRONTAGE RD SUITE 325
WOODRIDGE IL
60517-4903
US

V. Phone/Fax

Practice location:
  • Phone: 630-789-3422
  • Fax: 630-789-9093
Mailing address:
  • Phone: 630-789-3422
  • Fax: 630-789-9093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036094863
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036-094863
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: