Provider Demographics
NPI:1164411344
Name:THOMAS D NICHOLAS MD DANIEL J DWYER MD
Entity Type:Organization
Organization Name:THOMAS D NICHOLAS MD DANIEL J DWYER MD
Other - Org Name:ROCKVILLE TOWN SQUARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-569-2057
Mailing Address - Street 1:111 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47872-1735
Mailing Address - Country:US
Mailing Address - Phone:765-569-2057
Mailing Address - Fax:765-569-2340
Practice Address - Street 1:111 W HIGH ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47872-1735
Practice Address - Country:US
Practice Address - Phone:765-569-2057
Practice Address - Fax:765-569-2340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCD8603OtherRR MEDICARE
INCD8603OtherRR MEDICARE
IN620590Medicare PIN