Basic Information
| Provider Information | |||||||||
| NPI: | 1063596831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICOLOSI | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICOLOSI | ||||||||
| OtherFirstName: | CHARLES | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2031 32ND ST S | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546017099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087888103 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 116 MILL ST W. | ||||||||
| Address2: | |||||||||
| City: | CANNON FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550092027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087888103 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 11/14/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 20585 | MN | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 127T7NI | 01 | MN | BCBS MN | OTHER |