MEDICARE: LARA KATHRYN NICOL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036-122174	IL

General Provider Information

NPI Number	:	1124412374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARA KATHRYN NICOL M.D.

Provider Business Mailing Address
First Line	:	2511 N KEDZIE BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2603
Country	:	US
Telephone Number	:	773-292-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 N CICERO AVE STE 308
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1649
Country	:	US
Telephone Number	:	773-736-6125
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2015
Last Update Date	:	12/20/2021

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