=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568529303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTIC PAIN MANAGEMENT & REHABILITATION P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 09/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3210 N. CROATAN HWY BUILDING 3 SUITE 3
-----------------------------------------------------
City | KILL DEVIL HILLS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-261-5868
-----------------------------------------------------
Fax | 252-441-7793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3210 N. CROATAN HWY BUILDING 3 SUITE 3
-----------------------------------------------------
City | KILL DEVIL HILLS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-261-5868
-----------------------------------------------------
Fax | 252-441-7793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. THEODORE W NICHOLAS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 252-261-5868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 2002-0059
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------