Provider Demographics
NPI:1164665188
Name:RANDALL W. NICHOLS M D , PC
Entity Type:Organization
Organization Name:RANDALL W. NICHOLS M D , PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-677-6220
Mailing Address - Street 1:112 HAVEN DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 HAVEN DR
Practice Address - Street 2:SUITE 2
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2957
Practice Address - Country:US
Practice Address - Phone:334-677-6220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty