Provider Demographics
NPI:1083747810
Name:NICOLAS, PHILLIP (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10630 LITTLE PATUXENT PKWY
Mailing Address - Street 2:STE. 116
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6208
Mailing Address - Country:US
Mailing Address - Phone:410-992-7730
Mailing Address - Fax:
Practice Address - Street 1:10630 LITTLE PATUXENT PKWY
Practice Address - Street 2:STE. 116
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-6208
Practice Address - Country:US
Practice Address - Phone:410-992-7730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03382111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD390SMedicare PIN
MD6313830001Medicare UPIN
6313830001Medicare NSC