Healthcare Provider Details

I. General information

NPI: 1861575458
Provider Name (Legal Business Name): BOLGER FAMILY MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MEDICAL PLAZA PL
MINDEN LA
71055-3330
US

IV. Provider business mailing address

3 MEDICAL PLAZA PL
MINDEN LA
71055-3330
US

V. Phone/Fax

Practice location:
  • Phone: 318-377-7118
  • Fax: 318-377-7392
Mailing address:
  • Phone: 318-377-7118
  • Fax: 318-377-7392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14517R
License Number StateLA

VIII. Authorized Official

Name: JOSEPH EDWARD BOLGER
Title or Position: PRESIDENT
Credential: M.D., PHD
Phone: 318-377-7118