Healthcare Provider Details

I. General information

NPI: 1669418117
Provider Name (Legal Business Name): THERES J BOLUS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 4TH AVE S
BIRMINGHAM AL
35233-1511
US

IV. Provider business mailing address

1400 4TH AVE S
BIRMINGHAM AL
35233-1511
US

V. Phone/Fax

Practice location:
  • Phone: 205-329-7200
  • Fax: 205-329-7250
Mailing address:
  • Phone: 205-329-7200
  • Fax: 205-329-7250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00015368
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: