Provider Demographics
NPI:1659376721
Name:NICHOLSON, JEFFREY K (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:K
Last Name:NICHOLSON
Suffix:
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 1:2000A SOUTHBRIDGE PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-7718
Mailing Address - Country:US
Mailing Address - Phone:205-871-4274
Mailing Address - Fax:205-871-4301
Practice Address - Street 1:50 MEDICAL PARK DR E
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3401
Practice Address - Country:US
Practice Address - Phone:205-838-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL159582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009938631Medicaid
AL051502934Medicaid
AL051511408OtherBLUE CROSS
AL051539885OtherBLUE CROSS
AL051550140OtherBLUE CROSS
AL009984595Medicaid
AL051525169OtherBLUE CROSS
AL051550138Medicaid
AL051512694OtherBLUE CROSS
AL051550138OtherBLUE CROSS
AL051502934OtherBLUE CROSS
AL051512493OtherBLUE CROSS
AL051512495OtherBLUE CROSS
AL051550139OtherBLUE CROSS
AL051511408OtherBLUE CROSS
AL051550138Medicare PIN
AL051550139OtherBLUE CROSS
AL051512493OtherBLUE CROSS
AL051550138Medicaid
AL051550139Medicare PIN