Provider Demographics
NPI:1952393282
Name:JURICH, NICHOLAS ROGER (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ROGER
Last Name:JURICH
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 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:1279 OLD ABBOTT MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1889
Practice Address - Country:US
Practice Address - Phone:606-886-1760
Practice Address - Fax:606-886-3590
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64158884Medicaid
KYD92441Medicare UPIN
KYK053843Medicare PIN
KY1084801Medicare ID - Type Unspecified
KYK053841Medicare PIN
KYK053842Medicare PIN
KYK053840Medicare PIN