Provider Demographics
NPI:1043478142
Name:HAROLD R NICOLETTE, DO, PA
Entity type:Organization
Organization Name:HAROLD R NICOLETTE, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:NICOLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:843-766-4100
Mailing Address - Street 1:6 CARRIAGE LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6010
Mailing Address - Country:US
Mailing Address - Phone:843-766-4100
Mailing Address - Fax:843-571-4177
Practice Address - Street 1:6 CARRIAGE LN
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6010
Practice Address - Country:US
Practice Address - Phone:843-766-4100
Practice Address - Fax:843-571-4177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC001651Medicaid
SC001651Medicaid
SCE04850Medicare UPIN