Healthcare Provider Details

I. General information

NPI: 1992721393
Provider Name (Legal Business Name): LOUIS R BOLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E PLAZA DR STE 103
TALLAHASSEE FL
32308-5327
US

IV. Provider business mailing address

1605 E PLAZA DR STE 103
TALLAHASSEE FL
32308-5327
US

V. Phone/Fax

Practice location:
  • Phone: 850-878-7271
  • Fax: 850-878-1509
Mailing address:
  • Phone: 850-878-7271
  • Fax: 850-878-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberME74713
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: