Healthcare Provider Details

I. General information

NPI: 1205272739
Provider Name (Legal Business Name): NICHOLAS ALEXANDER BORM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 05/07/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E ONTARIO ST STE 300
CHICAGO IL
60611-3284
US

IV. Provider business mailing address

211 E ONTARIO ST STE 300
CHICAGO IL
60611-3284
US

V. Phone/Fax

Practice location:
  • Phone: 312-694-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA124654
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: