MEDICARE: DR. NICHOLAS ROGER LEROY D.C.

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	111NI0900X	Internist Chiropractor	038-007739	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001607135	OTHER	IL	BCBS
2	457811	OTHER	WI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1720120876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS ROGER LEROY D.C.

Provider Business Mailing Address
First Line	:	1002 W. LAKE STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607
Country	:	US
Telephone Number	:	312-243-3338
Fax Number	:

Provider Business Practice Location Address
First Line	:	1002 W. LAKE STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607
Country	:	US
Telephone Number	:	312-243-3338
Fax Number	:

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

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	06/30/2010

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