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General NPI Number Information
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NPI Number | 1114928835
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Entity Type | Individual
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Provider Name | NICHOLAS G STISO MD
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Gender | Male
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Dates
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Enumeration Date | 08/03/2005
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Last Update Date | 03/10/2016
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Provider Practice Location Address
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Address Line | 47 W POLK ST SUITE G
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City | CHICAGO
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State | IL
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Zip | 60605-2000
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Country | US
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Telephone | 312-922-3409
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Fax | 312-583-1712
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Provider Business Mailing Address
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Address Line | PO BOX 1152
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City | LA GRANGE PARK
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State | IL
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Zip | 60526-9252
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Country | US
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Telephone | 708-352-1202
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Fax | 708-352-7311
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036-072335
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301049152
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License Number State | MI
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