Healthcare Provider Details

I. General information

NPI: 1386986545
Provider Name (Legal Business Name): BENNETT ADAM BOLYARD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 S NATIONAL AVE SUITE 300
SPRINGFIELD MO
65807-7304
US

IV. Provider business mailing address

3231 S NATIONAL AVE SUITE 300
SPRINGFIELD MO
65807-7304
US

V. Phone/Fax

Practice location:
  • Phone: 417-888-5658
  • Fax: 417-841-0104
Mailing address:
  • Phone: 417-888-5658
  • Fax: 417-841-0104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34.011878
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2016012954
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: