Basic Information
| Provider Information | |||||||||
| NPI: | 1821054347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICO | ||||||||
| FirstName: | BAHRAM | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KORDLAR | ||||||||
| OtherFirstName: | BAHRAM | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5010 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587025010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575650 | ||||||||
| FaxNumber: | 7018575031 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 BURDICK EXPY W | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575421 | ||||||||
| FaxNumber: | 7018575427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 11161 | ND | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1454815 | 05 | ND | MEDICAID |