Healthcare Provider Details

I. General information

NPI: 1013744879
Provider Name (Legal Business Name): MIHAILO NIKOLIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-1000
US

IV. Provider business mailing address

1616 PECAN GRV
TUPELO MS
38801-7182
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5654
  • Fax: 309-672-5735
Mailing address:
  • Phone:
  • Fax:

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 Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209035930
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: