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General NPI Number Information
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NPI Number | 1841226909
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Entity Type | Individual
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Provider Name | CARLO G NICOLIS M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/23/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 200 STATE STREET SUITE 205
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City | MEDIA
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State | PA
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Zip | 19063-3434
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Country | US
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Telephone | 610-521-4112
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Fax | 610-521-6864
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Provider Business Mailing Address
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Address Line | PO BOX 95000-3505
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City | PHILA
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State | PA
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Zip | 19195-0001
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Country | US
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Telephone | 610-382-5900
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Fax | 610-382-5918
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | MD432640
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License Number State | PA
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