Healthcare Provider Details

I. General information

NPI: 1376333435
Provider Name (Legal Business Name): MICHAEL BOLUS MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2025
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE RM 202
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

169 ASHLEY AVE RM 202
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-2575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLL97401
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: