Provider Demographics
NPI:1578545554
Name:PRISCU, NICOLAS MARCUS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:MARCUS
Last Name:PRISCU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8111 S EMERSON AVE FL 5
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-8930
Practice Address - Fax:317-528-8532
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039800A207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000042357OtherMPLAN
IN000000578061OtherANTHEM
IN100350980Medicaid
IN10825775OtherCAQH
IN01039800BOtherCSR
INBP3161546OtherDEA
INM400071907Medicare UPIN
INBP3161546OtherDEA
F25710Medicare UPIN