Basic Information
| Provider Information | |||||||||
| NPI: | 1922066273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLAS | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11110 MEDICAL CAMPUS RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217426700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017144300 | ||||||||
| FaxNumber: | 3017144324 | ||||||||
| Practice Location | |||||||||
| Address1: | 11110 MEDICAL CAMPUS RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217426700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017144300 | ||||||||
| FaxNumber: | 3017144324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 09/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | D0033808 | MD | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 04339-1800 | 05 | MD | MEDICAID |