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General NPI Number Information
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NPI Number | 1174757983
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Entity Type | Individual
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Provider Name | CAROL E. TALISSE PA
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Gender | Female
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Dates
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Enumeration Date | 05/07/2009
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Last Update Date | 10/30/2020
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Provider Practice Location Address
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Address Line | 5115 N FRANCISCO AVE
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City | CHICAGO
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State | IL
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Zip | 60625-3611
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Country | US
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Telephone | 773-271-2225
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Fax | 773-271-1145
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Provider Business Mailing Address
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Address Line | 5019 N MOZART ST
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City | CHICAGO
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State | IL
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Zip | 60625-3615
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Country | US
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Telephone | 773-293-3223
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Fax | 773-293-4197
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 085-003354
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085003354
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License Number State | IL
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