Basic Information
| Provider Information | |||||||||
| NPI: | 1588191902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VON DER AHE | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 SHORTER AVE NW STE 201 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301654256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093300 | ||||||||
| FaxNumber: | 7062927653 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 CHATTAHOOCHEE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKMART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301532023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706847846 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 081963 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.