Healthcare Provider Details

I. General information

NPI: 1467582841
Provider Name (Legal Business Name): MADHAVI BOLARUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MADHAVI BOLARUM MD

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 7TH ST
FREDERICK MD
21701-4506
US

IV. Provider business mailing address

4007 BROADSTONE ST
FREDERICK MD
21704-7362
US

V. Phone/Fax

Practice location:
  • Phone: 240-566-3447
  • Fax:
Mailing address:
  • Phone: 240-575-9903
  • Fax: 240-205-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberD69035
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: