Healthcare Provider Details

I. General information

NPI: 1306086384
Provider Name (Legal Business Name): NICHOLS MOHS AND SKIN SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N KEENE ST SUITE 201
COLUMBIA MO
65201-7193
US

IV. Provider business mailing address

303 N KEENE ST SUITE 201
COLUMBIA MO
65201-7193
US

V. Phone/Fax

Practice location:
  • Phone: 573-876-1000
  • Fax: 573-442-7899
Mailing address:
  • Phone: 573-876-1000
  • Fax: 573-442-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2008016028
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number2008016028
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2008016028
License Number StateMO

VIII. Authorized Official

Name: DR. GEORGE RICHARD NICHOLS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 573-876-1000