Provider Demographics
NPI:1790851665
Name:THOMAS H. NOLEN, D.P.M., P.C.
Entity Type:Organization
Organization Name:THOMAS H. NOLEN, D.P.M., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:NOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:618-548-0057
Mailing Address - Street 1:624 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1403
Mailing Address - Country:US
Mailing Address - Phone:618-548-0057
Mailing Address - Fax:618-548-9611
Practice Address - Street 1:1313 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-3720
Practice Address - Country:US
Practice Address - Phone:618-242-8662
Practice Address - Fax:618-242-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004182213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60115194OtherBLUE CROSS / BLUE SHIELD OF ILLINOIS
IL016004182Medicaid
IL480025562Medicare PIN
IL016004182Medicaid
IL787812Medicare PIN