MEDICARE: DR. NIKOLA IVANCEVIC 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	213ES0131X	Foot Surgery Podiatrist	016-004831	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

General Provider Information

NPI Number	:	1972685410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NIKOLA IVANCEVIC DPM

Provider Business Mailing Address
First Line	:	5646 ST CHARLES RD
Second Line	:	SUITE B
City	:	BERKELEY
State	:	IL
Zip	:	60163
Country	:	US
Telephone Number	:	630-782-6557
Fax Number	:	630-782-6559

Provider Business Practice Location Address
First Line	:	5646 ST CHARLES RD
Second Line	:	SUITE B
City	:	BERKELEY
State	:	IL
Zip	:	60163
Country	:	US
Telephone Number	:	630-782-6557
Fax Number	:	630-782-6559

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	11/04/2016

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