MEDICARE: MICHAEL A NICHOLAS DO

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	207RC0000X	Cardiovascular Disease Physician	02000901A	IN
2	207RI0011X	Interventional Cardiology Physician	02000901A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	060030029	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000095311	OTHER	IN	ANTHEM PIN

General Provider Information

NPI Number	:	1598740748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL A NICHOLAS DO

Provider Business Mailing Address
First Line	:	160 CORNWALL DR
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-1006
Country	:	US
Telephone Number	:	708-297-0499
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 CORNWALL DR
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-1006
Country	:	US
Telephone Number	:	708-297-0499
Fax Number	:

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

Provider Enumeration Date	:	12/09/2005
Last Update Date	:	01/20/2026

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Directions to “ MICHAEL A NICHOLAS DO” Practice Location

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