Provider Demographics
NPI:1215955323
Name:NICHOLS, KAREN J (MD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:J
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 N 39TH ST
Mailing Address - Street 2:MAB, SUITE 212
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-8978
Mailing Address - Fax:215-662-5940
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:MAB, SUITE 212
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-8978
Practice Address - Fax:215-662-5940
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042926L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001431596Medicaid
PA667839Medicare ID - Type Unspecified
PA001431596Medicaid