Healthcare Provider Details

I. General information

NPI: 1487836284
Provider Name (Legal Business Name): TLC MEDICAL GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40W222 LA FOX ROAD SUITE J1
SAINT CHARLES IL
60175
US

IV. Provider business mailing address

40W222 LA FOX ROAD SUITE J1
SAINT CHARLES IL
60175
US

V. Phone/Fax

Practice location:
  • Phone: 630-513-9160
  • Fax: 630-513-9617
Mailing address:
  • Phone: 630-513-9160
  • Fax: 630-513-9617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036104024
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number03106052
License Number StateIL

VIII. Authorized Official

Name: DR. JONATHAN SONG
Title or Position: MANAGING PHYSICIAN
Credential:
Phone: 630-513-9160