Healthcare Provider Details

I. General information

NPI: 1346289105
Provider Name (Legal Business Name): CHARLES W NOLEN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 1ST WAY NW
FAYETTE AL
35555-1307
US

IV. Provider business mailing address

PO BOX 190
FAYETTE AL
35555-0190
US

V. Phone/Fax

Practice location:
  • Phone: 205-932-7821
  • Fax: 205-932-7684
Mailing address:
  • Phone: 205-932-7821
  • Fax: 205-932-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14531
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: