Basic Information
| Provider Information | |||||||||
| NPI: | 1720080229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2762 CONTINENTAL DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708083240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883135258 | ||||||||
| FaxNumber: | 2053135298 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 N BONITA AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324013623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883135258 | ||||||||
| FaxNumber: | 2053135298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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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 | 207P00000X | 72507 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 255405400 | 05 | FL | MEDICAID | 42672 | 01 | FL | BCBSF GRP # 98513 | OTHER |