Provider Demographics
NPI:1578922902
Name:MCNICHOLAS, BRIAN (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MCNICHOLAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:493 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1105
Mailing Address - Country:US
Mailing Address - Phone:708-674-4238
Mailing Address - Fax:
Practice Address - Street 1:667 EASTLAND AVE SE
Practice Address - Street 2:ST. JOSEPH WARREN HOSPITAL EMERGENCY DEPT
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4503
Practice Address - Country:US
Practice Address - Phone:330-841-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005946A207P00000X
390200000X
OH34.013992207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program