Provider Demographics
NPI:1518378629
Name:GEORGELOS, NICHOLAS PAUL (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PAUL
Last Name:GEORGELOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 MACOM DR STE 5
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-9362
Mailing Address - Country:US
Mailing Address - Phone:815-725-4918
Mailing Address - Fax:
Practice Address - Street 1:1890 SILVER CROSS BLVD STE 425
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9521
Practice Address - Country:US
Practice Address - Phone:815-725-4918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL1011208D00000X
IL036146903208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty