Provider Demographics
NPI:1679756001
Name:JORDAN NICHOLS
Entity Type:Organization
Organization Name:JORDAN NICHOLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-823-5077
Mailing Address - Street 1:135 N NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-823-5077
Mailing Address - Fax:847-823-0371
Practice Address - Street 1:135 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-823-5077
Practice Address - Fax:847-823-0371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5023100001Medicare NSC
ILT37817Medicare UPIN