Basic Information
| Provider Information | |||||||||
| NPI: | 1790851665 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THOMAS H. NOLEN, D.P.M., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628811403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185480057 | ||||||||
| FaxNumber: | 6185489611 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628643720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182428662 | ||||||||
| FaxNumber: | 6182424171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | NOLEN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6185480057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016-004182 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 60115194 | 01 | IL | BLUE CROSS / BLUE SHIELD OF ILLINOIS | OTHER | 016004182 | 05 | IL | MEDICAID |