MEDICARE: J TIMOTHY NICHOLS D.O.

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	02000537A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000081248	OTHER	IN	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	P01391909	OTHER	IN	RAIL ROAD PTAN

General Provider Information

NPI Number	:	1578569695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	J TIMOTHY NICHOLS D.O.

Provider Business Mailing Address
First Line	:	6626 E 75TH ST
Second Line	:	STE 500
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2805
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 N GIRLS SCHOOL RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46214-3963
Country	:	US
Telephone Number	:	317-247-0201
Fax Number	:	317-481-6756

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	06/11/2015

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