Healthcare Provider Details

I. General information

NPI: 1104806272
Provider Name (Legal Business Name): BRIAN NICKOLOFF MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S FIRST AVE (EMS BLDG., RM. 2209)
MAYWOOD IL
60153
US

IV. Provider business mailing address

2160 S FIRST AVE (EMS BLDG., RM. 2209)
MAYWOOD IL
60153
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-3250
  • Fax: 708-216-2620
Mailing address:
  • Phone: 708-216-3250
  • Fax: 708-216-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number36092377
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: