Healthcare Provider Details

I. General information

NPI: 1780301028
Provider Name (Legal Business Name): NICHOLAS IDEN DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2615 N FORREST LN
ARLINGTON HEIGHTS IL
60004-2241
US

V. Phone/Fax

Practice location:
  • Phone: 888-584-7888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041409236
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209026518
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: