Provider Demographics
NPI:1487907408
Name:MCNICHOLAS, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MCNICHOLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-5021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 CALLOWHILL ST STE 101
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-3658
Practice Address - Country:US
Practice Address - Phone:215-825-8220
Practice Address - Fax:215-825-8254
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN605632163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse