Provider Demographics
NPI:1255368361
Name:NICKISCHER, BRENT M (DO)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:M
Last Name:NICKISCHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 ENGLISH RD
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:PA
Mailing Address - Zip Code:18014-9210
Mailing Address - Country:US
Mailing Address - Phone:610-390-5596
Mailing Address - Fax:
Practice Address - Street 1:443 ENGLISH RD
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:PA
Practice Address - Zip Code:18014
Practice Address - Country:US
Practice Address - Phone:610-390-5596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008986L207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11585351OtherCAQH#
PA0311501OtherBLUE SHIELD
PAG48321Medicare UPIN