Healthcare Provider Details

I. General information

NPI: 1124098785
Provider Name (Legal Business Name): KEITH ANDREW NICHOLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 10/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TEMPLE ST SUITE 100
OWEGO NY
13827-1421
US

IV. Provider business mailing address

130 TEMPLE ST SUITE 100
OWEGO NY
13827-1421
US

V. Phone/Fax

Practice location:
  • Phone: 607-687-5616
  • Fax: 607-687-5989
Mailing address:
  • Phone: 607-687-5616
  • Fax: 607-687-5989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number141416
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: