Basic Information
| Provider Information | |||||||||
| NPI: | 1215955323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | MAB, SUITE 212 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156628978 | ||||||||
| FaxNumber: | 2156625940 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | MAB, SUITE 212 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156628978 | ||||||||
| FaxNumber: | 2156625940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD042926L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001431596 | 05 | PA | MEDICAID |