Healthcare Provider Details

I. General information

NPI: 1902850068
Provider Name (Legal Business Name): CHONG H NICHOLLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8075 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46250-2694
US

IV. Provider business mailing address

PO BOX 2336
MOUNTAIN HOME AR
72654-2336
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-8500
  • Fax:
Mailing address:
  • Phone: 870-424-7070
  • Fax: 870-424-6616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number37081
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.129284
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA80622
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01073755A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: