MEDICARE: DR NICHOLAS M TABOR III DPM

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	213E00000X	Podiatrist

General Provider Information

NPI Number	:	1619146016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR NICHOLAS M TABOR III DPM

Provider Business Mailing Address
First Line	:	1703 POLARIS CIR
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-1683
Country	:	US
Telephone Number	:	815-433-5600
Fax Number	:	815-434-0933

Provider Business Practice Location Address
First Line	:	1703 POLARIS CIR
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-1683
Country	:	US
Telephone Number	:	815-433-5600
Fax Number	:	815-434-0933

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NICHOLAS M TABOR III
Credential	:	DPM
Telephone Number	:	815-224-3535

Provider Enumeration Date	:	02/29/2008
Last Update Date	:	03/04/2008

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