1891981718 NPI number — MARK E. NICHOLS MD PA

Table of content: (NPI 1891981718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891981718 NPI number — MARK E. NICHOLS MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK E. NICHOLS MD PA
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:
Provider Other Organization Name Type Code:
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:
1891981718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18059 HIGHWAY 105 W
Provider Second Line Business Mailing Address:
SUITE125
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77356-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-582-5666
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18059 HIGHWAY 105 W
Provider Second Line Business Practice Location Address:
SUITE125
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77356-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-582-5666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
936-582-5666

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  L0457 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0042MP . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 174211601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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