Provider Demographics
NPI:1578596615
Name:NICKISCH, STEPHEN A (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:NICKISCH
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 1:2060 DAN PROCTOR DR
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3894
Mailing Address - Country:US
Mailing Address - Phone:912-540-6750
Mailing Address - Fax:912-540-6773
Practice Address - Street 1:2060 DAN PROCTOR DR
Practice Address - Street 2:SUITE 1200
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3894
Practice Address - Country:US
Practice Address - Phone:912-540-6750
Practice Address - Fax:912-540-6773
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10278207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000099105OtherBCBS
MT0093279Medicaid
011000188Medicare PIN
000099105OtherBCBS
F85582Medicare UPIN