Healthcare Provider Details

I. General information

NPI: 1376960237
Provider Name (Legal Business Name): NICHOLAS MAINS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DRIVE ROOM 4411
MORGANTOWN WV
26506
US

IV. Provider business mailing address

PO BOX 9214 1 MEDICAL CENTER DR, ROOM 4411
MORGANTOWN WV
26506-9214
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-1224
  • Fax: 304-293-1216
Mailing address:
  • Phone: 304-293-1224
  • Fax: 304-293-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3060
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3060
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number3060
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: