MEDICARE: ANDREA M NICHOLS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	207843	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053496422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA M NICHOLS MD

Provider Business Mailing Address
First Line	:	979 CROSS BRONX EXPY
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10460-4885
Country	:	US
Telephone Number	:	718-665-7565
Fax Number	:

Provider Business Practice Location Address
First Line	:	979 CROSS BRONX EXPY
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10460-4885
Country	:	US
Telephone Number	:	718-665-7565
Fax Number	:	718-665-7565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	04/10/2024

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