Provider Demographics
NPI:1518055979
Name:ADZICK, NICK SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:NICK
Middle Name:SCOTT
Last Name:ADZICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:N
Other - Middle Name:SCOTT
Other - Last Name:ADZICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:THE WANAMAKER BUILDING 9TH FL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9538
Mailing Address - Fax:267-425-9552
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-2730
Practice Address - Fax:215-590-4875
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD055694L2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001496572Medicaid
PAA66394Medicare UPIN
PA680388J5PMedicare ID - Type Unspecified