Provider Demographics
NPI:1861456568
Name:NICKELL, GARVIN (MD)
Entity Type:Individual
Prefix:
First Name:GARVIN
Middle Name:
Last Name:NICKELL
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 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5501
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:9313 S MASON MONTGOMERY RD
Practice Address - Street 2:STE. 200
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-8008
Practice Address - Country:US
Practice Address - Phone:513-584-6999
Practice Address - Fax:513-584-6998
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070234N207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2020986Medicaid
OH2020986Medicaid
G4417BMedicare UPIN
OHNI0817905Medicare PIN