Provider Demographics
NPI:1346421211
Name:KEITH A NICHOLS MD, PLLC
Entity Type:Organization
Organization Name:KEITH A NICHOLS MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-687-5616
Mailing Address - Street 1:130 TEMPLE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1408
Mailing Address - Country:US
Mailing Address - Phone:607-687-5616
Mailing Address - Fax:
Practice Address - Street 1:130 TEMPLE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1408
Practice Address - Country:US
Practice Address - Phone:607-687-5616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141416-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00709866Medicaid
NYBA0719Medicare PIN
NYB82245Medicare UPIN