Provider Demographics
NPI:1619578663
Name:NOLES MEDICAL SERVICES
Entity Type:Organization
Organization Name:NOLES MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-600-5589
Mailing Address - Street 1:351 CHANNELSIDE WALK WAY APT 4405
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-6765
Mailing Address - Country:US
Mailing Address - Phone:313-600-5589
Mailing Address - Fax:
Practice Address - Street 1:996 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2824
Practice Address - Country:US
Practice Address - Phone:313-600-5589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-05
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDI2018107000675Medicaid