MEDICARE: RICHARD CRAIG NIELSEN

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	ME106761	FL

General Provider Information

NPI Number	:	1538106125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD CRAIG NIELSEN

Provider Business Mailing Address
First Line	:	1021 PALM BROOK DR
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-1618
Country	:	US
Telephone Number	:	570-419-4446
Fax Number	:	321-600-4457

Provider Business Practice Location Address
First Line	:	1021 PALM BROOK DR
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-1618
Country	:	US
Telephone Number	:	570-419-4446
Fax Number	:	321-600-4457

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	03/17/2018

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