1346212750 NPI number — SUSAN ELAINE BOLDYS MD

Table of content: DOREEN JAHANPOUR (NPI 1295580249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346212750 NPI number — SUSAN ELAINE BOLDYS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLDYS
Provider First Name:
SUSAN
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1346212750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5650 W CENTRAL AVE STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43615-1510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-534-2888
Provider Business Mailing Address Fax Number:
419-534-2898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 W WOOSTER ST
Provider Second Line Business Practice Location Address:
WOOD COUNTY HOSPITAL
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43402-2603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-354-8977
Provider Business Practice Location Address Fax Number:
419-373-4157
Provider Enumeration Date:
02/02/2006

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: 207ZP0102X , with the licence number:  35045449B , 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: 0986278 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3403231100 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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