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Individual
NICHOLAS G STISO
Active
Individual
NICHOLAS G STISO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036-072335
IL
207R00000X
Internal Medicine Physician
4301049152
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110084980
RAILROAD MEDICARE
IL
01
—
31604458
BLUE CROSS BLUE SHIELD
IL
05
—
36072335
—
IL
01
—
950150135
MEDICARE PTAN
IL
Enumeration date
08/03/2005
Last updated
03/10/2016
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