Provider Demographics
NPI:1780622746
Name:NICOLA, TERRY L (MD, MS)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:NICOLA
Suffix:
Gender:M
Credentials:MD, MS
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:835 S WOLCOTT AVE
Mailing Address - Street 2:MC 844
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3748
Mailing Address - Country:US
Mailing Address - Phone:312-355-4404
Mailing Address - Fax:
Practice Address - Street 1:839 W ROOSEVELT RD
Practice Address - Street 2:SUITE #102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1530
Practice Address - Country:US
Practice Address - Phone:312-355-4404
Practice Address - Fax:312-413-7337
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360700372081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILB98009Medicare UPIN