Provider Demographics
NPI:1184235905
Name:NOLASCO MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:NOLASCO MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:NOLASCO MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-477-7472
Mailing Address - Street 1:2317 S BATES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4337
Mailing Address - Country:US
Mailing Address - Phone:866-477-7472
Mailing Address - Fax:217-717-2268
Practice Address - Street 1:2317 S BATES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4337
Practice Address - Country:US
Practice Address - Phone:866-477-7472
Practice Address - Fax:217-717-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-14
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0005XAllopathic & Osteopathic PhysiciansInternal MedicineHypertension SpecialistGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100698048OtherMEDICARE PTAN