Basic Information
| Provider Information | |||||||||
| NPI: | 1093162760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLLS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 CHURCHILL DR | ||||||||
| Address2: | |||||||||
| City: | MAYLENE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351145413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052135861 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 SIVLEY RD SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562651000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2016 | ||||||||
| LastUpdateDate: | 09/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 38154 | AL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.