Basic Information
| Provider Information | |||||||||
| NPI: | 1922196575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 WILSON ST | ||||||||
| Address2: | |||||||||
| City: | MILES CITY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593015094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062332500 | ||||||||
| FaxNumber: | 4062332611 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 WILSON ST | ||||||||
| Address2: | |||||||||
| City: | MILES CITY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593015094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062332500 | ||||||||
| FaxNumber: | 4062332611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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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 | 208600000X | 12569 | MT | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A421210 | 05 | CA | MEDICAID |