Basic Information
| Provider Information | |||||||||
| NPI: | 1699762336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIKKEL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490906743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696375271 | ||||||||
| FaxNumber: | 2696392818 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490906743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696375271 | ||||||||
| FaxNumber: | 2696392818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 36100980 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1023138633 | 01 | IL | GROUP NPI NUMBER | OTHER | 31622992 | 01 | IL | BCBS | OTHER | 036-100980 | 01 | IL | STATE LICENSE NUMBER | OTHER | 036100980 | 05 | IL | MEDICAID |