Active NPI
Phillip Nicodemus, CRNA
- Anesthesiology Physician
- Martinsburg, WV
National Provider Identifier
1417917899
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Anesthesiology Physician
- License
- 33379
- Practice address
- 94 Old Mill Rd
Martinsburg, WV 25401-9284 - Phone
- (304) 264-8933
- Fax
- (304) 264-8846
- NPI assigned
- Mar 28, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Anesthesiology Physician | 207L00000X | 33379 | WV | Primary |
Addresses
Primary practice location
94 Old Mill Rd
Martinsburg, WV 25401-9284
Mailing address
94 Old Mill Rd
Martinsburg, WV 25401-9284
Phone (304) 264-8933
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0068750000 | Medicaid | WV |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 33379 | WV | MD | Anesthesiology Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Eastern Panhandle Anesthesia Associates | Past | Accepting new patients | |
| Advanced Anesthesia Group, PLLC | Anesthesiology | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Anesthesiology Physician
- Martinsburg, WV
- NPI 1619284197
-
- Pain Medicine (Anesthesiology) Physician
- Martinsburg, WV
- NPI 1902866882
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1143504000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1783900800000",
"number": "1417917899",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "94 OLD MILL RD",
"city": "MARTINSBURG",
"state": "WV",
"postal_code": "254019284",
"telephone_number": "304-264-8933",
"fax_number": "304-264-8846"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "94 OLD MILL RD",
"city": "MARTINSBURG",
"state": "WV",
"postal_code": "254019284",
"telephone_number": "304-264-8933",
"fax_number": "304-264-8846"
}
],
"practiceLocations": [],
"basic": {
"last_name": "NICODEMUS",
"first_name": "PHILLIP",
"credential": "CRNA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-03-28",
"last_updated": "2026-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "207L00000X",
"taxonomy_group": "",
"desc": "Anesthesiology",
"state": "WV",
"license": "33379",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0068750000",
"state": "WV"
}
],
"endpoints": [],
"other_names": []
}Other providers in Martinsburg, WV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.