Provider Demographics
NPI:1043210164
Name:NICELY, ERIC R (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:R
Last Name:NICELY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9724 KINGSTON PIKE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3347
Mailing Address - Country:US
Mailing Address - Phone:865-690-0602
Mailing Address - Fax:865-690-0515
Practice Address - Street 1:7557 DANNAHER LN
Practice Address - Street 2:SUITE 230
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3558
Practice Address - Country:US
Practice Address - Phone:865-637-9431
Practice Address - Fax:865-637-8887
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000019805208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1669416442OtherGROUP NPI
TN3106070OtherBLUE CROSS
TNCI2260OtherRAILROAD MEDICARE
TN3106086OtherBLUE CROSS
TN3084254Medicaid
TN3714756Medicare PIN
TN3084257Medicare ID - Type Unspecified
TN1260440001Medicare NSC
TN1669416442OtherGROUP NPI
TN3084254Medicaid