Provider Demographics
NPI:1235138546
Name:NIELSEN, THOMAS J (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 W HARRISON ST
Mailing Address - Street 2:SUITE 550
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:312-942-6100
Mailing Address - Fax:312-942-6225
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:SUITE 550
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-942-6100
Practice Address - Fax:312-942-6225
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072375207Y00000X
IL036-072375207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072375Medicaid
ILCB1567OtherRRMC
IL036072375Medicaid
ILL03994Medicare PIN
ILE18388Medicare UPIN
IL040007046Medicare PIN