Healthcare Provider Details

I. General information

NPI: 1639179930
Provider Name (Legal Business Name): TIMOTHY S BOLLOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD
BEND OR
97701-4283
US

IV. Provider business mailing address

2200 NE NEFF RD STE 200
BEND OR
97701-4283
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-3344
  • Fax: 541-382-1681
Mailing address:
  • Phone: 541-382-3344
  • Fax: 541-382-1681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD25128
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: