MEDICARE: DR. TRISTA NEGELE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	036-092361	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1633552	OTHER	IL	BCBS PROVIDER ID

General Provider Information

NPI Number	:	1407842321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRISTA NEGELE MD

Provider Business Mailing Address
First Line	:	800 BIESTERFIELD RD
Second Line	:	SUITE 2004
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3361
Country	:	US
Telephone Number	:	874-952-7375
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 BIESTERFIELD RD
Second Line	:	SUITE 2004
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3361
Country	:	US
Telephone Number	:	847-952-7375
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	04/01/2014

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