Provider Demographics
NPI:1912065756
Name:NICHOL, BRAD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:
Last Name:NICHOL
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 1:1830 BLAKE AVE
Mailing Address - Street 2:#202 ROARING FORK SURGICAL
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601
Mailing Address - Country:US
Mailing Address - Phone:970-945-6533
Mailing Address - Fax:970-945-3945
Practice Address - Street 1:1830 BLAKE AVE
Practice Address - Street 2:#202 ROARING FORK SURGICAL
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601
Practice Address - Country:US
Practice Address - Phone:970-945-6533
Practice Address - Fax:970-945-3945
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO38600208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30886830Medicaid
CO465128Medicare ID - Type Unspecified
H65900Medicare UPIN