Basic Information
| Provider Information | |||||||||
| NPI: | 1639180045 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TPN LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7447 W TALCOTT AVE | ||||||||
| Address2: | SUITE 436 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606313745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737747224 | ||||||||
| FaxNumber: | 7737742550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | NASSOS | ||||||||
| AuthorizedOfficialFirstName: | TASSOS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7737747224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | DF0861 | 01 | IL | RAILROAD MEDICARE | OTHER | 21602528 | 01 | IL | BCBS PROVIDER ID | OTHER |