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General NPI Number Information
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NPI Number | 1639267040
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Entity Type | Individual
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Provider Name | EDWARD PETER NIKICICZ M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 07/02/2009
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Provider Practice Location Address
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Address Line | 801 S ADAMS ST SRMC, LAB
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City | PETERSBURG
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State | VA
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Zip | 23803-5149
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Country | US
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Telephone | 804-862-5028
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Fax |
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Provider Business Mailing Address
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Address Line | 3908 MCTYRES COVE CT
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City | MIDLOTHIAN
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State | VA
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Zip | 23112-4665
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Country | US
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Telephone | 804-744-6140
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | VA0101047885
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License Number State | VA
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