Basic Information
| Provider Information | |||||||||
| NPI: | 1902054216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | EVANSTON HOSPITAL | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702114 | ||||||||
| FaxNumber: | 8475701223 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | EVANSTON HOSPITAL | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702114 | ||||||||
| FaxNumber: | 8475701223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2008 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036124285 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2083A0300X | 036-124285 | IL | N | 207PT0002X | 036124285 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology |
No ID Information.