Individual
DR. MARK RYAN NIKKEL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
955 S BAILEY AVE, SOUTH HAVEN, MI 49090-6743
(269) 637-5271
(269) 639-2818
Mailing address
955 S BAILEY AVE, SOUTH HAVEN, MI 49090-6743
(269) 637-5271
(269) 639-2818
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
36100980
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036-100980
STATE LICENSE NUMBER
IL
05
—
036100980
—
IL
01
—
1023138633
GROUP NPI NUMBER
IL
01
—
31622992
BCBS
IL
Enumeration date
09/27/2005
Last updated
11/27/2023
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