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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1376787556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLIVAR PHYSICIAN PRACTICES LLC

Provider Business Mailing Address
First Line	:	218 N PEARMAN AVE
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2634
Country	:	US
Telephone Number	:	662-298-1730
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 N PEARMAN AVE
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2634
Country	:	US
Telephone Number	:	662-298-1730
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT N KLEIN
Credential	:
Telephone Number	:	662-843-8885

Provider Enumeration Date	:	05/01/2009
Last Update Date	:	05/01/2009

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