MEDICARE: ELIZABETH DEMOS NICHOLSON M.D.

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	207P00000X	Emergency Medicine Physician	A86767	CA
2	207P00000X	Emergency Medicine Physician	6623361-1205	UT
3	207P00000X	Emergency Medicine Physician	6623361-8905	UT

General Provider Information

NPI Number	:	1245262229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH DEMOS NICHOLSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 30180
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84130-0180
Country	:	US
Telephone Number	:	801-269-2500
Fax Number	:	801-269-2690

Provider Business Practice Location Address
First Line	:	5121 S. COTTONWOOD STREET
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84157
Country	:	US
Telephone Number	:	801-269-2500
Fax Number	:	801-269-2690

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	05/24/2011

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