1437135373 NPI number — MR. ANTHONY BRADLEY BOLAND M.D.

Table of content: QUEENDOLYN RASCO (NPI 1427925270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437135373 NPI number — MR. ANTHONY BRADLEY BOLAND M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLAND
Provider First Name:
ANTHONY
Provider Middle Name:
BRADLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1437135373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 N STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39216-4500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-984-2680
Provider Business Mailing Address Fax Number:
601-815-4563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-984-2680
Provider Business Practice Location Address Fax Number:
601-815-4563
Provider Enumeration Date:
12/22/2005

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: 2086S0129X , with the licence number:  MD29549 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: 044417 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: MD00022869 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: 20979 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07188733 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100033107 . This is a "PHP TENNCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4078780 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3153656 . This is a "BLUECROSS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 62178953301 . This is a "JOHN DEERE HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0140040322 . This is a "CIGNA HMO" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3740047 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 00832917B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009965915 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56812 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: P01189946 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 3812941 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8490567 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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