Provider Demographics
NPI:1003895632
Name:TALLEY, NICHOLAS JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:TALLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-2000
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32557207RG0100X
FLMFC1616207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN416318400Medicaid
MN110025925Medicare ID - Type UnspecifiedRAILROAD
MN416318400Medicaid
MN100000443Medicare ID - Type Unspecified
FLAI097ZMedicare PIN