1316415672 NPI number — BRANDON BOLDUC PA-C

Table of content: BRANDON BOLDUC PA-C (NPI 1316415672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316415672 NPI number — BRANDON BOLDUC PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLDUC
Provider First Name:
BRANDON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1316415672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
380 SUMMIT AVENUE
Provider Second Line Business Mailing Address:
MSO PHYSICIAN BILLING
Provider Business Mailing Address City Name:
STEUBENVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43952-2667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-283-7597
Provider Business Mailing Address Fax Number:
740-283-7807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 PLAZA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLAIRSVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43950-6700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-318-1794
Provider Business Practice Location Address Fax Number:
234-285-6816
Provider Enumeration Date:
11/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2180 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 50.006507RX , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0330256 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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