1063049468 NPI number — NICOLAS MANUEL ESPINOSA MD

Table of content: NICOLAS MANUEL ESPINOSA MD (NPI 1063049468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063049468 NPI number — NICOLAS MANUEL ESPINOSA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESPINOSA
Provider First Name:
NICOLAS
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063049468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
675 N ST. CLAIR
Provider Second Line Business Mailing Address:
GALTER PAVILION, 15TH FLOOR, ROOM 200
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-695-8182
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 E HURON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60611-2908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-926-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: 125.075492 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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