Provider Demographics
NPI:1760469993
Name:NIBLACK, BRETT CLAYTON (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:CLAYTON
Last Name:NIBLACK
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 W GROVER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3825
Practice Address - Country:US
Practice Address - Phone:980-487-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300075207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89135FTMedicaid
135FTOtherBCBS
NC1760469993Medicaid
BN8347696OtherDEA
C7715OtherMEDCOST
3248271OtherAETNA US HEALTH
701227OtherUHC
2111327OtherMAMSI
560943383JOtherCIGNA
7504471OtherAETNA
SCN00078Medicaid
P00219792OtherRAILROAD MEDICARE
560943383JOtherCIGNA
H86691Medicare UPIN
BN8347696OtherDEA
NCNCG760AMedicare PIN