Healthcare Provider Details

I. General information

NPI: 1750439345
Provider Name (Legal Business Name): CHRISTINE M BOLEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/28/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HAWTHORNE LN SUITE 100
CHARLOTTE NC
28204-2450
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1900
  • Fax: 704-384-1919
Mailing address:
  • Phone: 704-384-1900
  • Fax: 704-384-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0062257
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number2007-01081
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: