MEDICARE: DR. THOMAS J NIELSEN 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	207Y00000X	Otolaryngology Physician	036072375	IL
2	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	036-072375	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	CB1567	OTHER	IL	RRMC

General Provider Information

NPI Number	:	1235138546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS J NIELSEN M.D.

Provider Business Mailing Address
First Line	:	1611 W HARRISON ST
Second Line	:	SUITE 550
City	:	CHICAGO
State	:	IL
Zip	:	60612-4861
Country	:	US
Telephone Number	:	312-942-6100
Fax Number	:	312-942-6225

Provider Business Practice Location Address
First Line	:	1611 W HARRISON ST
Second Line	:	SUITE 550
City	:	CHICAGO
State	:	IL
Zip	:	60612-4861
Country	:	US
Telephone Number	:	312-942-6100
Fax Number	:	312-942-6225

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	05/04/2011

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