MEDICARE: DR. FLORIAN NICKISCH 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	207X00000X	Orthopaedic Surgery Physician	2005-01034	NC
2	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician	6475000-1205	UT

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598748725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FLORIAN NICKISCH MD

Provider Business Mailing Address
First Line	:	590 WAKARA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1200
Country	:	US
Telephone Number	:	801-587-5486
Fax Number	:	801-587-5411

Provider Business Practice Location Address
First Line	:	590 WAKARA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1200
Country	:	US
Telephone Number	:	801-587-5486
Fax Number	:	801-587-5411

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	11/23/2021

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