Healthcare Provider Details

I. General information

NPI: 1982602454
Provider Name (Legal Business Name): RADOSLAV S.B. NICHOLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RADOSLAV STEVAN NICHOLAS M.D.

II. Dates (important events)

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

III. Provider practice location address

1990 HOLTON AVE E
BIG STONE GAP VA
24219-3350
US

IV. Provider business mailing address

PO BOX CC
BIG STONE GAP VA
24219-0690
US

V. Phone/Fax

Practice location:
  • Phone: 276-523-7938
  • Fax: 276-523-7028
Mailing address:
  • Phone: 276-523-7938
  • Fax: 276-523-7028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101036556
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: