Basic Information
| Provider Information | |||||||||
| NPI: | 1043210164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICELY | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9724 KINGSTON PIKE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656900602 | ||||||||
| FaxNumber: | 8656900515 | ||||||||
| Practice Location | |||||||||
| Address1: | 7557 DANNAHER LN | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | POWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378493558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656379431 | ||||||||
| FaxNumber: | 8656378887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 12/07/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD0000019805 | TN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1669416442 | 01 | TN | GROUP NPI | OTHER | 3106070 | 01 | TN | BLUE CROSS | OTHER | CI2260 | 01 | TN | RAILROAD MEDICARE | OTHER | 3106086 | 01 | TN | BLUE CROSS | OTHER | 3084254 | 05 | TN | MEDICAID |