Healthcare Provider Details

I. General information

NPI: 1184235905
Provider Name (Legal Business Name): NOLASCO MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 S BATES AVE
SPRINGFIELD IL
62704-4337
US

IV. Provider business mailing address

2317 S BATES AVE
SPRINGFIELD IL
62704-4337
US

V. Phone/Fax

Practice location:
  • Phone: 866-477-7472
  • Fax: 217-717-2268
Mailing address:
  • Phone: 866-477-7472
  • Fax: 217-717-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0005X
TaxonomyHypertension Specialist Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CARLOS ERNESTO NOLASCO MORALES
Title or Position: PRESIDENT AND CEO
Credential: M.D.
Phone: 866-477-7472