MEDICARE: MR. CHONG H NICHOLLS 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	207L00000X	Anesthesiology Physician	37081	CO
2	207L00000X	Anesthesiology Physician	35.129284	OH
3	207L00000X	Anesthesiology Physician	A80622	CA
4	207L00000X	Anesthesiology Physician	01073755A	IN

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

General Provider Information

NPI Number	:	1902850068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHONG H NICHOLLS MD

Provider Business Mailing Address
First Line	:	PO BOX 2336
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72654-2336
Country	:	US
Telephone Number	:	870-424-7070
Fax Number	:	870-424-6616

Provider Business Practice Location Address
First Line	:	8075 N SHADELAND AVE STE 200
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2694
Country	:	US
Telephone Number	:	317-621-8500
Fax Number	:

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	06/05/2024

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