Provider Demographics
NPI:1609874247
Name:RUSSEL NICHOLS, MD, PC
Entity Type:Organization
Organization Name:RUSSEL NICHOLS, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-575-2669
Mailing Address - Street 1:135 FORD RD
Mailing Address - Street 2:
Mailing Address - City:JOHN DAY
Mailing Address - State:OR
Mailing Address - Zip Code:97845-2010
Mailing Address - Country:US
Mailing Address - Phone:541-575-2669
Mailing Address - Fax:541-575-2743
Practice Address - Street 1:135 FORD RD
Practice Address - Street 2:
Practice Address - City:JOHN DAY
Practice Address - State:OR
Practice Address - Zip Code:97845-2010
Practice Address - Country:US
Practice Address - Phone:541-575-2669
Practice Address - Fax:541-575-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00039026OtherWA LICENSE NUMBER
4532990001OtherNSC/DME
OR287633Medicaid
4532990001OtherNSC/DME
113883Medicare ID - Type Unspecified