Healthcare Provider Details

I. General information

NPI: 1083602718
Provider Name (Legal Business Name): THOMAS H. NOLEN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 W MAIN ST
SALEM IL
62881-1403
US

IV. Provider business mailing address

624 W MAIN ST
SALEM IL
62881-1403
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-0057
  • Fax: 618-548-9611
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:
Title or Position:
Credential:
Phone: