Healthcare Provider Details

I. General information

NPI: 1538498472
Provider Name (Legal Business Name): BRIAN S NILES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 FULTON ST
BLYTHEVILLE AR
72315-1922
US

IV. Provider business mailing address

609 FULTON ST
BLYTHEVILLE AR
72315-1922
US

V. Phone/Fax

Practice location:
  • Phone: 870-763-0855
  • Fax: 870-763-0858
Mailing address:
  • Phone: 870-763-0855
  • Fax: 870-763-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2009034738
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberE-7820
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: