1639171994 NPI number — DR. ALAN M BOLASH MD

Table of content: DR. ALAN M BOLASH MD (NPI 1639171994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639171994 NPI number — DR. ALAN M BOLASH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLASH
Provider First Name:
ALAN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1639171994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3998 FAIR RIDGE DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22033-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-766-9737
Provider Business Mailing Address Fax Number:
703-766-9725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
659 HOSPITAL RD
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
TAPPAHANNOCK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-433-6020
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2005

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: 207L00000X , with the licence number:  0101035140 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00570516-9 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 050001075 . This is a "MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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