Provider Demographics
NPI:1376505867
Name:NICHOLLS, CHAD (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:NICHOLLS
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 1:144 S 500 E
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3460 PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2049
Practice Address - Country:US
Practice Address - Phone:801-964-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6068204-1205207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6585Medicaid
UT005568651Medicare PIN
UT005786139Medicare PIN
UTD6585Medicaid
UT005568569Medicare PIN
UTI28729Medicare UPIN
UT005568368Medicare PIN
UT005568463Medicare PIN
UT005567248Medicare PIN