Provider Demographics
NPI:1306870001
Name:NICHOLAS, BLAINEY J (MD)
Entity type:Individual
Prefix:
First Name:BLAINEY
Middle Name:J
Last Name:NICHOLAS
Suffix:
Gender:M
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:PO BOX 403
Mailing Address - Street 2:
Mailing Address - City:LABADIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70372-0403
Mailing Address - Country:US
Mailing Address - Phone:504-376-3161
Mailing Address - Fax:
Practice Address - Street 1:602 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4847
Practice Address - Country:US
Practice Address - Phone:504-837-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022044207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1974692Medicaid
LA5U012Medicare ID - Type Unspecified
LA1974692Medicaid