Provider Demographics
NPI:1952830036
Name:NOLL, STANLEY JAY (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:JAY
Last Name:NOLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 530
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:IL
Mailing Address - Zip Code:62644-0530
Mailing Address - Country:US
Mailing Address - Phone:309-543-6600
Mailing Address - Fax:866-950-0320
Practice Address - Street 1:615 N PROMENADE ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:IL
Practice Address - Zip Code:62644-1243
Practice Address - Country:US
Practice Address - Phone:309-543-6600
Practice Address - Fax:866-950-0320
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.070704207Q00000X
IL036153332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine