Provider Demographics
NPI:1477532141
Name:NICHOLSON, GREGORY P (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:P
Last Name:NICHOLSON
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 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:#240
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:STE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-243-4244
Practice Address - Fax:312-942-1517
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105551207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207073OtherMEDICARE PTAN LOCALITY #15
IL207067OtherMEDICARE PTAN LOCALITY #16
IL4247771OtherAETNA PROVIDER NUMBER
ILP00065134OtherRR MEDICARE PROVIDER NUMBER
ILDA4902OtherRR MEDICARE PTAN NUMBER
IL1633878OtherBCBS PROVIDER NUMBER
ILK01194Medicare PIN
IL4247771OtherAETNA PROVIDER NUMBER
ILDA4902OtherRR MEDICARE PTAN NUMBER