MEDICARE: DR. CORNELIUS IOAN NICOLL 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	207X00000X	Orthopaedic Surgery Physician	MA30263	NJ

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	260407100	OTHER	NJ	US DEPT OF LABOR

General Provider Information

NPI Number	:	1548364581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORNELIUS IOAN NICOLL M.D.

Provider Business Mailing Address
First Line	:	33 N FULLERTON AVE
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-3412
Country	:	US
Telephone Number	:	973-783-3734
Fax Number	:	973-783-0144

Provider Business Practice Location Address
First Line	:	33 N FULLERTON AVE
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-3412
Country	:	US
Telephone Number	:	973-783-3734
Fax Number	:	973-783-0144

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

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. CORNELIUS IOAN NICOLL M.D.” Practice Location

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