Provider Demographics
NPI:1548438435
Name:NICELY, CHRISTOPHER CORY (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:CORY
Last Name:NICELY
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:PO BOX 5307
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-5307
Mailing Address - Country:US
Mailing Address - Phone:866-497-8222
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6379
Practice Address - Country:US
Practice Address - Phone:304-243-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV247142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0075347Medicaid
WV1548438435Medicaid
PA1037733420001Medicaid