Provider Demographics
NPI:1588658272
Name:NICKS, GREGG F (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:F
Last Name:NICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-780-2497
Mailing Address - Fax:270-783-0454
Practice Address - Street 1:1225 FAIRWAY STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2477
Practice Address - Country:US
Practice Address - Phone:270-781-3910
Practice Address - Fax:270-842-7177
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY37824207Q00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64061393Medicaid
080194783OtherRAILROAD MEDICARE
0622328Medicare PIN
B59069Medicare UPIN