Healthcare Provider Details

I. General information

NPI: 1639136377
Provider Name (Legal Business Name): THOMAS RICHARD BOLT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9313 MEDICAL PLAZA DRIVE STE 202
N CHARLESTON SC
29406
US

IV. Provider business mailing address

PO BOX 530062
ATLANTA GA
30353-0062
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-1200
  • Fax: 843-553-0424
Mailing address:
  • Phone: 843-695-6071
  • Fax: 843-569-5879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10991
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: