Provider Demographics
NPI:1730181371
Name:NICOL, THEODORE H (CRNA)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:H
Last Name:NICOL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 711052
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-0001
Mailing Address - Country:US
Mailing Address - Phone:614-457-8180
Mailing Address - Fax:614-583-3300
Practice Address - Street 1:500 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8971
Practice Address - Country:US
Practice Address - Phone:614-898-6659
Practice Address - Fax:614-898-8631
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.01738-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH430040270OtherRAILROAD MEDICARE
OH0690999Medicaid
OH0690999Medicaid
OHNI8200593Medicare PIN