Healthcare Provider Details

I. General information

NPI: 1316935034
Provider Name (Legal Business Name): ROBERT J BOOLBOL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SOUTH RD SUITE 250
FARMINGTON CT
06032
US

IV. Provider business mailing address

11350 MCCORMICK RD EXECUTIVE PLAZA 1, SUITE 501
HUNT VALLEY MD
21031
US

V. Phone/Fax

Practice location:
  • Phone: 860-674-0222
  • Fax: 860-674-0024
Mailing address:
  • Phone: 410-329-1071
  • Fax: 410-329-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number040205
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number040205
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number040205
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: