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Organization
NOLASCO MEDICAL GROUP, PLLC
Active
Organization
NOLASCO MEDICAL GROUP, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CARLOS ERNESTO NOLASCO MORALES M.D. (PRESIDENT AND CEO)
(866) 477-7472
Entity
Organization
Contact information
Practice address
2317 S BATES AVE, SPRINGFIELD, IL 62704-4337
(866) 477-7472
(217) 717-2268
Mailing address
2317 S BATES AVE, SPRINGFIELD, IL 62704-4337
(866) 477-7472
(217) 717-2268
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
207RH0005X
Hypertension Specialist Physician
—
—
2084P0800X
Psychiatry Physician
—
—
2084P0804X
Child & Adolescent Psychiatry Physician
—
—
261QP2300X
Primary Care Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
F100698048
MEDICARE PTAN
IL
Enumeration date
08/14/2020
Last updated
12/01/2020
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