MEDICARE: BRADLEY WILLIAM NICHOLSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	0101030962	VA

General Provider Information

NPI Number	:	1144227836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY WILLIAM NICHOLSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1019
Second Line	:
City	:	STUART
State	:	VA
Zip	:	24171-1019
Country	:	US
Telephone Number	:	276-694-4466
Fax Number	:	276-694-2909

Provider Business Practice Location Address
First Line	:	18877 JEB STUART HWY
Second Line	:
City	:	STUART
State	:	VA
Zip	:	24171
Country	:	US
Telephone Number	:	276-694-4466
Fax Number	:	276-694-2909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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