Basic Information
| Provider Information | |||||||||
| NPI: | 1962449942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOHLERMAN | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6190 GEORGETOWN BLVD | ||||||||
| Address2: | |||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217846460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105525050 | ||||||||
| FaxNumber: | 4105520200 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 RIVERVIEW AVE STE 710 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235101065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572529010 | ||||||||
| FaxNumber: | 7575109287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D37606 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0101273192 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 556781500 | 05 | MD | MEDICAID |