Basic Information
| Provider Information | |||||||||
| NPI: | 1376983346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AHN | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | CHO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 19648 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175454735 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 N RUTLEDGE ST | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175454735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2013 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301114315 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084P0800X | 125.064175 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207R00000X | 036-141124 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036141124 | 05 | IL | MEDICAID |