Basic Information
| Provider Information | |||||||||
| NPI: | 1487655163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NENADOVICH | ||||||||
| FirstName: | NIKOLA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 GATEWAY BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199211444 | ||||||||
| FaxNumber: | 2199215303 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 GATEWAY BLVD N | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463049658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199211444 | ||||||||
| FaxNumber: | 2199215303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 01058786A | IN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | 01058786A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 200476580 | 05 | IN | MEDICAID |