Healthcare Provider Details

I. General information

NPI: 1053060566
Provider Name (Legal Business Name): NICHOLAS STEWART DEAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 20-150
CHICAGO IL
60611-5979
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 20-150
CHICAGO IL
60611-5979
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8146
  • Fax: 312-695-7030
Mailing address:
  • Phone: 312-695-8146
  • Fax: 312-695-7030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036161142
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: