Healthcare Provider Details

I. General information

NPI: 1063074094
Provider Name (Legal Business Name): NICHOLAS MARCEL DE LA RUA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2019
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE STE 542
CHICAGO IL
60631-3716
US

IV. Provider business mailing address

7447 W TALCOTT AVE STE 542
CHICAGO IL
60631-3716
US

V. Phone/Fax

Practice location:
  • Phone: 773-631-2180
  • Fax: 773-631-5947
Mailing address:
  • Phone: 773-631-2180
  • Fax: 773-631-5947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.075168
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036.159353
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036.159353
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036159353
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: