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General NPI Number Information
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NPI Number | 1487836284
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Entity Type | Organization
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Legal Business Name | TLC MEDICAL GROUP, S.C.
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 01/14/2019
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Provider Practice Location Address
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Address Line | 40W222 LA FOX ROAD SUITE J1
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City | SAINT CHARLES
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State | IL
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Zip | 60175
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Country | US
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Telephone | 630-513-9160
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Fax | 630-513-9617
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Provider Business Mailing Address
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Address Line | 40W222 LA FOX ROAD SUITE J1
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City | SAINT CHARLES
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State | IL
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Zip | 60175
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Country | US
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Telephone | 630-513-9160
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Fax | 630-513-9617
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Authorized Official
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Title or Position | MANAGING PHYSICIAN
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Name | DR. JONATHAN SONG
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Credential |
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Telephone | 630-513-9160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 036104024
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 03106052
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License Number State | IL
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