Provider Demographics
NPI:1841226909
Name:NICOLIS, CARLO G (MD)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:G
Last Name:NICOLIS
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:PO BOX 95000-3505
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-0001
Mailing Address - Country:US
Mailing Address - Phone:610-382-5900
Mailing Address - Fax:610-382-5918
Practice Address - Street 1:200 STATE STREET
Practice Address - Street 2:SUITE 205
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3434
Practice Address - Country:US
Practice Address - Phone:610-521-4112
Practice Address - Fax:610-521-6864
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD432640OtherLIC NUMBER
PAMD432640OtherLIC NUMBER
PA120362XDKMedicare PIN
BN9440328OtherDEA
PAMD432640OtherLIC NUMBER