Provider Demographics
NPI:1669460481
Name:NICHOLSON, BRUCE D (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:1259 S CEDAR CREST BLVD STE 317
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103
Practice Address - Country:US
Practice Address - Phone:610-402-1757
Practice Address - Fax:610-402-9089
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2018-12-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD046894L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012842940Medicaid
PA0432922-002OtherCIGNA
PA1234452OtherTHREE RIVERS
PAP2616744OtherOXFORD
PA0559065000OtherINDEP. BLUE CROSS
PA07721766OtherGATEWAY
PA20008174OtherAMERIHEALTH MERCY
PA30000048OtherKEYSTONE MERCY
PA815211OtherAETNA
PA1284294OtherHIGHMARK
PA01216902OtherCAP BLUE CROSS
PA0721766OtherKHP CENTRAL
PA30000048OtherKEYSTONE MERCY
PA0721766OtherKHP CENTRAL
PA720000079Medicare PIN