MEDICARE: BOLIVAR PHYSICIAN PRACTICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician

General Provider Information

NPI Number	:	1316388416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLIVAR PHYSICIAN PRACTICES LLC

Provider Business Mailing Address
First Line	:	907 E SUNFLOWER RD STE 103
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2830
Country	:	US
Telephone Number	:	662-846-9990
Fax Number	:	662-846-5444

Provider Business Practice Location Address
First Line	:	907 E SUNFLOWER RD
Second Line	:	SUITE 103
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2830
Country	:	US
Telephone Number	:	662-846-9990
Fax Number	:	662-846-5444

Authorized Official
Title or Position	:	SECRETARY
Name	:	CHARLOTTE E LAWRENCE
Credential	:
Telephone Number	:	615-920-7000

Provider Enumeration Date	:	07/17/2013
Last Update Date	:	06/04/2026

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