Healthcare Provider Details

I. General information

NPI: 1902982150
Provider Name (Legal Business Name): PETER A NICKLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 EDGEMERE
GROSSE POINTE FARMS MI
48236
US

IV. Provider business mailing address

47 EDGEMERE
GROSSE POINTE FARMS MI
48236
US

V. Phone/Fax

Practice location:
  • Phone: 313-886-4367
  • Fax:
Mailing address:
  • Phone: 313-886-4367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number4301037905
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number4301037905
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: