Provider Demographics
NPI:1205843653
Name:NICHOLSON, KIERAN JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:KIERAN
Middle Name:JOSEPH
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KIERAN
Other - Middle Name:JOSEPH
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7803 DREW AVE
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6946
Mailing Address - Country:US
Mailing Address - Phone:630-650-8392
Mailing Address - Fax:630-317-3310
Practice Address - Street 1:7803 DREW AVE
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-6946
Practice Address - Country:US
Practice Address - Phone:630-650-8392
Practice Address - Fax:630-317-3310
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-076743207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076743Medicaid
IL036076743OtherBC/BS
IL110216107OtherRAILROAD MEDICARE ID
IL110216107OtherRAILROAD MEDICARE ID
ILE66669Medicare UPIN