Healthcare Provider Details

I. General information

NPI: 1255439642
Provider Name (Legal Business Name): ROGER ANTHONY NOSAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR DEPARTMENT OF FAMILY MEDICINE
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

2168 N LAKE SHORE CIR
ARLINGTON HEIGHTS IL
60004-7201
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-3300
  • Fax: 773-665-3228
Mailing address:
  • Phone: 847-398-2362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: