1265497671 NPI number — CRISPIN G. BOLISAY, MD APMC

Table of content: GREGORY C. MORRIS P.T. (NPI 1043214943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265497671 NPI number — CRISPIN G. BOLISAY, MD APMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRISPIN G. BOLISAY, MD APMC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265497671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
SLIDELL
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70461-5544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-646-0360
Provider Business Mailing Address Fax Number:
985-646-0362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
SLIDELL
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70461-5544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-646-0360
Provider Business Practice Location Address Fax Number:
985-646-0362
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOLISAY
Authorized Official First Name:
CRISPIN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
985-646-0360

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1443476 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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