Provider Demographics
NPI:1396744652
Name:NICHOLS, PHILLIP TODD (MD)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:TODD
Last Name:NICHOLS
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 1628
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25326-1628
Mailing Address - Country:US
Mailing Address - Phone:304-342-0124
Mailing Address - Fax:304-340-2204
Practice Address - Street 1:500 DONNALLY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1648
Practice Address - Country:US
Practice Address - Phone:304-342-0124
Practice Address - Fax:304-340-2204
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19053207Y00000X
VA0101273372207YX0007X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV040014129OtherRR MEDICARE
WV1157768001OtherCIGNA
WV0300079000Medicaid
WV7979026OtherAETNA
WV550595497023OtherBC/BS
WV7979026OtherAETNA