Healthcare Provider Details

I. General information

NPI: 1780622746
Provider Name (Legal Business Name): TERRY L NICOLA M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 W ROOSEVELT RD SUITE #102
CHICAGO IL
60608-1530
US

IV. Provider business mailing address

835 S WOLCOTT AVE MC 844
CHICAGO IL
60612-3748
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-4404
  • Fax: 312-413-7337
Mailing address:
  • Phone: 312-355-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number036070037
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: