Provider Demographics
NPI:1619146016
Name:DR NICHOLAS M TABOR III DPM
Entity Type:Organization
Organization Name:DR NICHOLAS M TABOR III DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:III
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-224-3535
Mailing Address - Street 1:1703 POLARIS CIR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1683
Mailing Address - Country:US
Mailing Address - Phone:815-433-5600
Mailing Address - Fax:815-434-0933
Practice Address - Street 1:1703 POLARIS CIR
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1683
Practice Address - Country:US
Practice Address - Phone:815-433-5600
Practice Address - Fax:815-434-0933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR NICHOLAS M TABOR III DPM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-29
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1296560002Medicare NSC