Provider Demographics
NPI:1598740748
Name:NICHOLAS, MICHAEL A (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:NICHOLAS
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2150 GETTLER ST STE 400
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2385
Practice Address - Country:US
Practice Address - Phone:219-865-0893
Practice Address - Fax:219-865-3599
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000901A207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000095311OtherANTHEM PIN
060030029OtherRR MEDICARE
IN406090BMedicare PIN
IL572870Medicare PIN
IN000000095311OtherANTHEM PIN
IN406310BMedicare PIN