Healthcare Provider Details

I. General information

NPI: 1568632008
Provider Name (Legal Business Name): BRUCE R BOLLING & GWENDOLYN W BOLLING PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 02/03/2011
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 Code208600000X
TaxonomySurgery Physician
License Number592
License Number StateNC

VIII. Authorized Official

Name: BRUCE BOLLING
Title or Position: OWNER
Credential: MD
Phone: 336-659-9440