Provider Demographics
NPI:1114928835
Name:STISO, NICHOLAS G (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:G
Last Name:STISO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1152
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-9252
Mailing Address - Country:US
Mailing Address - Phone:708-352-1202
Mailing Address - Fax:708-352-7311
Practice Address - Street 1:47 W POLK ST
Practice Address - Street 2:SUITE G
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2000
Practice Address - Country:US
Practice Address - Phone:312-922-3409
Practice Address - Fax:312-583-1712
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072335207R00000X
MI4301049152207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110084980OtherRAILROAD MEDICARE
IL31604458OtherBLUE CROSS BLUE SHIELD
IL36072335Medicaid
IL950150135OtherMEDICARE PTAN
C43821Medicare UPIN