Healthcare Provider Details

I. General information

NPI: 1790851665
Provider Name (Legal Business Name): THOMAS H. NOLEN, D.P.M., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 MAIN ST
MOUNT VERNON IL
62864-3720
US

IV. Provider business mailing address

624 W MAIN ST
SALEM IL
62881-1403
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-8662
  • Fax: 618-242-4171
Mailing address:
  • Phone: 618-548-0057
  • Fax: 618-548-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016-004182
License Number StateIL

VIII. Authorized Official

Name: DR. THOMAS H. NOLEN
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 618-548-0057