Provider Demographics
NPI:1700331907
Name:NOKOMIS MEDICAL GROUP
Entity Type:Organization
Organization Name:NOKOMIS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-562-2131
Mailing Address - Street 1:107 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:IL
Mailing Address - Zip Code:62075-1658
Mailing Address - Country:US
Mailing Address - Phone:217-563-8343
Mailing Address - Fax:217-563-2285
Practice Address - Street 1:107 W STATE ST
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:IL
Practice Address - Zip Code:62075-1658
Practice Address - Country:US
Practice Address - Phone:217-563-8343
Practice Address - Fax:217-563-2285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care