1912072968 NPI number — THOMAS H. NOLEN, D.P.M., P.C.

Table of content: (NPI 1912072968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912072968 NPI number — THOMAS H. NOLEN, D.P.M., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMAS H. NOLEN, D.P.M., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912072968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62881-1403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-548-0057
Provider Business Mailing Address Fax Number:
618-548-9611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 N DAVIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62801-3339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-532-9008
Provider Business Practice Location Address Fax Number:
618-532-7764
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NOLEN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-548-0057

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  016-004182 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 016004182 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6106004 . This is a "BLUE CROSS / BLUE SHIELD OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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