Healthcare Provider Details

I. General information

NPI: 1609874247
Provider Name (Legal Business Name): RUSSEL NICHOLS, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 FORD RD
JOHN DAY OR
97845-2010
US

IV. Provider business mailing address

135 FORD RD
JOHN DAY OR
97845-2010
US

V. Phone/Fax

Practice location:
  • Phone: 541-575-2669
  • Fax: 541-575-2743
Mailing address:
  • Phone: 541-575-2669
  • Fax: 541-575-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD22062
License Number StateOR

VIII. Authorized Official

Name: RUSSEL JAMES NICHOLS
Title or Position: OWNER
Credential: MD
Phone: 541-575-2669