Basic Information
Provider Information | |||||||||
NPI: | 1902850068 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICHOLLS | ||||||||
FirstName: | CHONG | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2336 | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | AR | ||||||||
PostalCode: | 726542336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8704247070 | ||||||||
FaxNumber: | 8704246616 | ||||||||
Practice Location | |||||||||
Address1: | 624 HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | AR | ||||||||
PostalCode: | 726532955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8705081000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 07/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35.129284 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | A80622 | CA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 37081 | CO | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 01073755A | IN | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 201216590 | 05 | IN |   | MEDICAID | 01370816 | 05 | CA |   | MEDICAID | 188700001 | 05 | AR |   | MEDICAID |