Healthcare Provider Details

I. General information

NPI: 1144221201
Provider Name (Legal Business Name): SYLVESTOR D. NICOL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 NUCKOLLS RD
BOLIVAR TN
38008-1532
US

IV. Provider business mailing address

640 NUCKOLLS RD
BOLIVAR TN
38008-1532
US

V. Phone/Fax

Practice location:
  • Phone: 731-659-2273
  • Fax: 731-659-2272
Mailing address:
  • Phone: 731-659-2273
  • Fax: 731-659-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29302
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: