Healthcare Provider Details

I. General information

NPI: 1639176464
Provider Name (Legal Business Name): JAMES EDWIN BOLANDER II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 S EAST ST STE H
INDIANAPOLIS IN
46227-1939
US

IV. Provider business mailing address

120 W 22ND ST STE 200
OAK BROOK IL
60523-1563
US

V. Phone/Fax

Practice location:
  • Phone: 317-924-8425
  • Fax: 317-924-8424
Mailing address:
  • Phone: 630-573-5000
  • Fax: 317-882-2873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01039451
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01039451A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: