Healthcare Provider Details

I. General information

NPI: 1972758126
Provider Name (Legal Business Name): REBECCA BOLLIN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 FRANKLIN ST
KEOSAUQUA IA
52565-1164
US

IV. Provider business mailing address

304 FRANKLIN ST
KEOSAUQUA IA
52565-1164
US

V. Phone/Fax

Practice location:
  • Phone: 319-293-3171
  • Fax: 319-293-3473
Mailing address:
  • Phone: 319-293-3171
  • Fax: 319-293-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4235
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: