Basic Information
| Provider Information | |||||||||
| NPI: | 1467532085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | TRENT | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 N OAK AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317835857 | ||||||||
| FaxNumber: | 9315266760 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385014294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317832770 | ||||||||
| FaxNumber: | 9315251176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 05/15/2017 | ||||||||
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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 | 208M00000X | 18410 | TN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 4352400 | 01 | TN | BCBS | OTHER | 3047248 | 05 | TN | MEDICAID | 64795180 | 05 | KY | MEDICAID |