Provider Demographics
NPI:1740546589
Name:BALTRUSHES HUGHES, NICOLE CORY (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CORY
Last Name:BALTRUSHES HUGHES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BALTRUSHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2840 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2938
Mailing Address - Country:US
Mailing Address - Phone:773-395-7400
Mailing Address - Fax:
Practice Address - Street 1:2840 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647
Practice Address - Country:US
Practice Address - Phone:773-395-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036141648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN