Healthcare Provider Details

I. General information

NPI: 1104867936
Provider Name (Legal Business Name): MICHAEL J BOLAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 BAPTIST BLVD SUITE 402
COLUMBUS MS
39705
US

IV. Provider business mailing address

PO BOX 405827
ATLANTA GA
30384-5827
US

V. Phone/Fax

Practice location:
  • Phone: 662-240-1412
  • Fax: 662-240-1949
Mailing address:
  • Phone: 901-227-4068
  • Fax: 901-227-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number6387
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number056686
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number00027291
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number06387
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: