Provider Demographics
NPI:1396715157
Name:NICHOLS, CLAY A (MD)
Entity type:Individual
Prefix:DR
First Name:CLAY
Middle Name:A
Last Name:NICHOLS
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 751069
Mailing Address - Street 2:ECU PHYSICIANS
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:ECU PHYSICIANS PATHOLOGY
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4300
Practice Address - Country:US
Practice Address - Phone:252-744-2803
Practice Address - Fax:252-744-3616
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13038174400000X
NC2011-00202207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1396715157Medicaid
NC185CZOtherBCBS NC
SCGP3481Medicaid
SC010678285OtherTAX-ID
SC010678285OtherTAX-ID
NC185CZOtherBCBS NC
SCQ334730001Medicare ID - Type UnspecifiedMEDICARE
NCNCI1810322Medicare PIN