Basic Information
| Provider Information | |||||||||
| NPI: | 1750350559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 WAYNE ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457503300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403737999 | ||||||||
| FaxNumber: | 7403733151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 34-00-8658 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 34-00-8658 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2612579 | 05 | OH | MEDICAID | 3810005284 | 05 | WV | MEDICAID |