Healthcare Provider Details

I. General information

NPI: 1043325970
Provider Name (Legal Business Name): MICHAEL JOSEPH BOLGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N BALLAS RD CANCER CENTER
SAINT LOUIS MO
63131-2329
US

IV. Provider business mailing address

3015 N BALLAS RD CANCER CENTER
SAINT LOUIS MO
63131-2329
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5425
  • Fax: 314-996-5390
Mailing address:
  • Phone: 314-996-5425
  • Fax: 314-996-5390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number102120
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: