1558323246 NPI number — RANDALL J. BOLAR M.D.

Table of content: DR. DMITRY LEONGARDT M.D. (NPI 1174549554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558323246 NPI number — RANDALL J. BOLAR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLAR
Provider First Name:
RANDALL
Provider Middle Name:
J.
Provider Name Prefix Text:
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:
1558323246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1027 WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT LAKES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56501-3409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-847-5611
Provider Business Mailing Address Fax Number:
218-847-0881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1027 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-3409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-5611
Provider Business Practice Location Address Fax Number:
218-847-0881
Provider Enumeration Date:
04/06/2006

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: 208600000X , with the licence number:  34949 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 36945 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1515147 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: TN0125 . This is a "AMERICHOICE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 203500913011 . This is a "TRICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000069481 . This is a "ANTHEM BC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 10802394 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1558323246 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01281517 . This is a "AMERIGROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4221186 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 64357130 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7774037 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3338849 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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