MEDICARE: NICOLA J CHERRY MD LLC

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	208000000X	Pediatrics Physician	MD21778	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760415525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLA J CHERRY MD LLC

Provider Business Mailing Address
First Line	:	PO BOX 1359
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-0075
Country	:	US
Telephone Number	:	541-882-1540
Fax Number	:	541-882-2583

Provider Business Practice Location Address
First Line	:	2580 DAGGETT AVE
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-1127
Country	:	US
Telephone Number	:	541-884-1224
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLA J CHERRY
Credential	:	M.D.
Telephone Number	:	541-884-1224

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	08/21/2009

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