Basic Information
Provider Information | |||||||||
NPI: | 1083602718 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NOLEN | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | H. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 624 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | IL | ||||||||
PostalCode: | 628811403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185480057 | ||||||||
FaxNumber: | 6185489611 | ||||||||
Practice Location | |||||||||
Address1: | 624 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | IL | ||||||||
PostalCode: | 628811403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185480057 | ||||||||
FaxNumber: | 6185489611 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2005 | ||||||||
LastUpdateDate: | 05/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016-004182 | IL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 135686 | 01 | IL | HEALTHLINK | OTHER | 60115194 | 01 | IL | BCBS, MTVERNON, IL OFFIC | OTHER | 016004182 | 05 | IL |   | MEDICAID | 6106002 | 01 | IL | BCBS, SALEM, IL OFFICE | OTHER | 6106004 | 01 | IL | BCBS, CENTRALIA, IL OF | OTHER |