MEDICARE: NICHOLAS G STISO 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	207R00000X	Internal Medicine Physician	036-072335	IL
2	207R00000X	Internal Medicine Physician	4301049152	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110084980	OTHER	IL	RAILROAD MEDICARE
4	950150135	OTHER	IL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	31604458	OTHER	IL	BLUE CROSS BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114928835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS G STISO MD

Provider Business Mailing Address
First Line	:	PO BOX 1152
Second Line	:
City	:	LA GRANGE PARK
State	:	IL
Zip	:	60526-9252
Country	:	US
Telephone Number	:	708-352-1202
Fax Number	:	708-352-7311

Provider Business Practice Location Address
First Line	:	47 W POLK ST
Second Line	:	SUITE G
City	:	CHICAGO
State	:	IL
Zip	:	60605-2000
Country	:	US
Telephone Number	:	312-922-3409
Fax Number	:	312-583-1712

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

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	03/10/2016

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Directions to “ NICHOLAS G STISO MD” Practice Location

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