Healthcare Provider Details

I. General information

NPI: 1780686311
Provider Name (Legal Business Name): ROWAN REECE NICKOL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 LOONEY RD SUITE 204
PIQUA OH
45356-4199
US

IV. Provider business mailing address

280 LOONEY RD SUITE 204
PIQUA OH
45356-4199
US

V. Phone/Fax

Practice location:
  • Phone: 937-773-4123
  • Fax: 937-773-7717
Mailing address:
  • Phone: 937-773-4123
  • Fax: 937-773-7717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number47329
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: