Provider Demographics
NPI:1831185206
Name:NICKELL, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:NICKELL
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 1:2040 W. 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804
Mailing Address - Country:US
Mailing Address - Phone:417-627-1300
Mailing Address - Fax:417-627-1357
Practice Address - Street 1:2040 W. 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-627-1300
Practice Address - Fax:417-627-1357
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9A40174400000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO20896OtherBNDD
MO931523261Medicare PIN
MO20896OtherBNDD
MOA10173Medicare UPIN