Healthcare Provider Details

I. General information

NPI: 1548217466
Provider Name (Legal Business Name): ROBERT F BOLL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23120 N LAGRANGE RD
FRANKFORT IL
60423-7760
US

IV. Provider business mailing address

23120 N LAGRANGE RD
FRANKFORT IL
60423-7760
US

V. Phone/Fax

Practice location:
  • Phone: 815-464-5440
  • Fax: 815-936-5404
Mailing address:
  • Phone: 815-464-5440
  • Fax: 815-936-5404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036077868
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: