Provider Demographics
NPI:1780686311
Name:NICKOL, ROWAN REECE (MD)
Entity Type:Individual
Prefix:
First Name:ROWAN
Middle Name:REECE
Last Name:NICKOL
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 1:280 LOONEY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-4199
Mailing Address - Country:US
Mailing Address - Phone:937-773-4123
Mailing Address - Fax:937-773-7717
Practice Address - Street 1:280 LOONEY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-4199
Practice Address - Country:US
Practice Address - Phone:937-773-4123
Practice Address - Fax:937-773-7717
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH47329208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0572983Medicaid
OH0240840OtherGR MEDICAID NUMBER
MI9912194OtherGR MEDICARE NUMBER
A17343Medicare UPIN
MI9912194OtherGR MEDICARE NUMBER
OHNI0613196Medicare PIN