Individual Professional Information |
|
NPI
|
1821102302
|
|
Unique healthcare provider (clinician) ID assigned by NPPES
|
|
PECOS UID
|
5496852386
|
|
Unique individual clinician ID assigned by PECOS
|
|
Professional Enrollment ID
|
I20110203000422
|
|
Unique ID for the individual professional enrollment that is the source for the data in the observation
|
|
Provider Last Name
|
NUCKOLS
|
|
Individual professional last name
|
|
Provider First Name
|
JOSEPH
|
|
Individual professional first name
|
|
Provider Middle Name
|
D
|
|
Individual professional middle name
|
|
Provider Gender
|
M
|
|
The provider's gender if the provider is a person.
|
Practice Information |
|
Organization Legal Name
|
HCT PATHOLOGY SERVICES LLC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
2961509856
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
20
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
2401 W BELEVEDERE AVE
|
|
Group Practice or individual's line 1 address
|
|
City
|
BALTIMORE
|
|
Group Practice or individual's city
|
|
State
|
MD
|
|
Group Practice or individual's state
|
|
Zip Code
|
212155216
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
4106018733
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
210012
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
SINAI HOSPITAL OF BALTIMORE
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
210040
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
NORTHWEST HOSPITAL CENTER
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
210049
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
UNIVERSITY OF MD UPPER CHESAPEAKE MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Hospital Affiliation CCN 4
|
210033
|
|
Medicare CCN of hospital where individual professional provides service 4
|
|
Hospital Affiliation LBN 4
|
CARROLL HOSPITAL CENTER
|
|
Legal business name of hospital where individual professional provides service 4
|
|
Hospital Affiliation CCN 5
|
210006
|
|
Medicare CCN of hospital where individual professional provides service 5
|
|
Hospital Affiliation LBN 5
|
UNIVERSITY OF MD HARFORD MEMORIAL HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 5
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|