Healthcare Provider Details

I. General information

NPI: 1205896941
Provider Name (Legal Business Name): MARIA RITA BOLISAY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 MILLIS AVE SUITE 101
BOONVILLE IN
47601-2242
US

IV. Provider business mailing address

1116 MILLIS AVE SUITE 101
BOONVILLE IN
47601-2242
US

V. Phone/Fax

Practice location:
  • Phone: 812-897-7383
  • Fax: 812-897-7236
Mailing address:
  • Phone: 812-897-7383
  • Fax: 812-897-7236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01047204
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: