Healthcare Provider Details

I. General information

NPI: 1710515838
Provider Name (Legal Business Name): PHILLIP NICHOLS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date: 07/17/2023
Reactivation Date: 08/01/2023

III. Provider practice location address

4111 1ST AVE STE 3
NITRO WV
25143-1345
US

IV. Provider business mailing address

400 ASSOCIATION DR STE 102
CHARLESTON WV
25311-1298
US

V. Phone/Fax

Practice location:
  • Phone: 304-755-4797
  • Fax: 304-755-4799
Mailing address:
  • Phone: 304-388-1724
  • Fax: 304-388-1721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4139
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4139
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: