Provider Demographics
NPI:1639171598
Name:NICHOLAS, ALEXANDER S (DO)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:S
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 1:4190 CITY LINE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-871-6425
Mailing Address - Fax:215-871-6490
Practice Address - Street 1:4190 CITY LINE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-6425
Practice Address - Fax:215-871-6490
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003496L204D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000700018Medicaid
D98754Medicare UPIN
PA000700018Medicaid