Healthcare Provider Details

I. General information

NPI: 1700275823
Provider Name (Legal Business Name): JEFFERY A BOLLENBACHER DO PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 S 7TH ST STE 1A
TERRE HAUTE IN
47802-5710
US

IV. Provider business mailing address

PO BOX 3402
TERRE HAUTE IN
47803-0402
US

V. Phone/Fax

Practice location:
  • Phone: 812-234-4243
  • Fax: 812-478-3663
Mailing address:
  • Phone: 812-234-4243
  • Fax: 812-478-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberIN02001578
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberIN02001578
License Number StateIN

VIII. Authorized Official

Name: JEFFERY A BOLLENBACHER
Title or Position: ORTHOPEDIC SURGEON
Credential: D.O.
Phone: 812-234-4243