Provider Demographics
NPI:1144285826
Name:MCNICHOLS, DAVID W (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:MCNICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:D
Other - Middle Name:W
Other - Last Name:MCNICHOLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1169
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-1169
Mailing Address - Country:US
Mailing Address - Phone:217-342-9738
Mailing Address - Fax:217-342-9806
Practice Address - Street 1:414 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2258
Practice Address - Country:US
Practice Address - Phone:217-342-9738
Practice Address - Fax:217-342-9806
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361036581208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL068148OtherHEALTHALLIANCE
IL0361036581Medicaid
IL2500053OtherBCBS
IL340018705OtherRAILROAD MEDICARE IDENT.#
IL451985OtherHEALTHLINK
ILCC9824OtherRAILROAD MEDICARE
ILCC9824OtherRAILROAD MEDICARE
ILL82524Medicare ID - Type Unspecified
IL592530Medicare PIN