Individual
DR. GREGORY P. NICHOLSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1611 W HARRISON ST, STE, CHICAGO, IL 60612-3841
(312) 243-4244
(312) 942-1517
Mailing address
1 WESTBROOK CORPORATE CTR, #240, WESTCHESTER, IL 60154-5701
Taxonomy
Speciality
Code
Description
License number
State
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
Primary
036105551
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1633878
BCBS PROVIDER NUMBER
IL
01
—
207067
MEDICARE PTAN LOCALITY #16
IL
01
—
207073
MEDICARE PTAN LOCALITY #15
IL
01
—
4247771
AETNA PROVIDER NUMBER
IL
01
—
DA4902
RR MEDICARE PTAN NUMBER
IL
01
—
P00065134
RR MEDICARE PROVIDER NUMBER
IL
Enumeration date
01/11/2006
Last updated
09/18/2018
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