Healthcare Provider Details

I. General information

NPI: 1942231477
Provider Name (Legal Business Name): CHARLES G NICHOLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 03/07/2023
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 CHURCH ST STE 101
PIKEVILLE KY
41501-3476
US

IV. Provider business mailing address

7145 E VIRGINIA ST STE 2000
EVANSVILLE IN
47715-9147
US

V. Phone/Fax

Practice location:
  • Phone: 606-432-5660
  • Fax: 606-432-2738
Mailing address:
  • Phone: 812-962-7894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number16295
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: