Provider Demographics
NPI:1235303009
Name:R C NICHOLS JR MD PA
Entity Type:Organization
Organization Name:R C NICHOLS JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROMAINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-769-0009
Mailing Address - Street 1:PO BOX 2506
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32402-2506
Mailing Address - Country:US
Mailing Address - Phone:850-769-0009
Mailing Address - Fax:850-769-0070
Practice Address - Street 1:615 N BONITA AVE
Practice Address - Street 2:BAY REGIONAL CANCER CENTER
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3623
Practice Address - Country:US
Practice Address - Phone:850-747-6972
Practice Address - Fax:850-747-6584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056785261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15097OtherBLUE CROSS OF FLORIDA
FLK8820Medicare PIN