1750734232 NPI number — MARSHALL S. NICKEL, MD PLLC

Table of content: (NPI 1750734232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750734232 NPI number — MARSHALL S. NICKEL, MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARSHALL S. NICKEL, MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UPFAMILYMEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750734232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 GLEN MEADOW CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEHURST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28374-8242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-420-0044
Provider Business Mailing Address Fax Number:
253-218-6964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 GLEN MEADOW CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEHURST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28374-8242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-414-9047
Provider Business Practice Location Address Fax Number:
253-218-6964
Provider Enumeration Date:
07/19/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NICKEL
Authorized Official First Name:
MARSHALL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
910-420-0044

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD60216841 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)