Provider Demographics
NPI:1639115496
Name:NICHOLS, PHILLIP LYNN II (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LYNN
Last Name:NICHOLS
Suffix:II
Gender:M
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:PO BOX 94670
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-4670
Mailing Address - Country:US
Mailing Address - Phone:405-682-3303
Mailing Address - Fax:405-384-6793
Practice Address - Street 1:2240 SUTHERLAND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919
Practice Address - Country:US
Practice Address - Phone:865-588-8831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37082207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3880610Medicaid
TN290015399OtherRR MEDICARE PIN
TN290015399OtherRR MEDICARE PIN
H35318Medicare UPIN
TN3717547Medicare ID - Type UnspecifiedLEGACY GROUP