Provider Demographics
NPI:1528461720
Name:KYLE NICKEL MD, PC
Entity type:Organization
Organization Name:KYLE NICKEL MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:NICKEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-929-1609
Mailing Address - Street 1:95 STAFFORD LN
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-3465
Mailing Address - Country:US
Mailing Address - Phone:970-874-8026
Mailing Address - Fax:
Practice Address - Street 1:95 STAFFORD LN
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-3465
Practice Address - Country:US
Practice Address - Phone:970-874-8026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33012208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48638013Medicaid
CO48638013Medicaid
COCU8148Medicare PIN