Provider Demographics
NPI:1609854389
Name:NICHOLSON, PHYLLIS E (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:E
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PICCARD DRIVE
Mailing Address - Street 2:STE 202
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4303
Mailing Address - Country:US
Mailing Address - Phone:301-921-7900
Mailing Address - Fax:301-921-7915
Practice Address - Street 1:18101 PRINCE PHILIP DRIVE
Practice Address - Street 2:MONTGOMERY GENERAL HOSPITAL
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832
Practice Address - Country:US
Practice Address - Phone:301-774-8900
Practice Address - Fax:301-570-8574
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0028429207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD665192E14Medicare ID - Type Unspecified
C33575Medicare UPIN
VA665192E14Medicare ID - Type Unspecified