Healthcare Provider Details

I. General information

NPI: 1720195571
Provider Name (Legal Business Name): BRUCE RICHARD BOLLING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 MAPLEWOOD AVE
WINSTON SALEM NC
27103-4020
US

IV. Provider business mailing address

3001 MAPLEWOOD AVE
WINSTON SALEM NC
27103-4020
US

V. Phone/Fax

Practice location:
  • Phone: 336-659-9440
  • Fax: 336-659-9845
Mailing address:
  • Phone: 336-659-9440
  • Fax: 336-659-9845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number592
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: