Provider Demographics
NPI:1891842514
Name:CHARLES W. NOLEN, JR., M.D., P.C.
Entity Type:Organization
Organization Name:CHARLES W. NOLEN, JR., M.D., P.C.
Other - Org Name:FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:NOLEN, JR.
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-932-7821
Mailing Address - Street 1:1705 1ST WAY NW
Mailing Address - Street 2:P.O. BOX 190
Mailing Address - City:FAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:35555-1307
Mailing Address - Country:US
Mailing Address - Phone:205-932-7821
Mailing Address - Fax:205-932-7684
Practice Address - Street 1:1705 1ST WAY NW
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555-1307
Practice Address - Country:US
Practice Address - Phone:205-932-7821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD80510Medicare UPIN
AL82650Medicare ID - Type Unspecified