Provider Demographics
NPI:1083778468
Name:BREMER, NICHOLAS JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:BREMER
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 1:5191 FIRST COAST TECH PKWY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224
Mailing Address - Country:US
Mailing Address - Phone:904-223-3321
Mailing Address - Fax:904-223-2169
Practice Address - Street 1:1699 S 14TH ST STE 16
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1965
Practice Address - Country:US
Practice Address - Phone:904-223-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126043208VP0000X, 208VP0000X
WV26716208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108108900Medicaid
WV9296571OtherGROUP MEDICARE
WV0011253000OtherGROUP MEDICAID