Healthcare Provider Details

I. General information

NPI: 1104855808
Provider Name (Legal Business Name): CLINICAL PARTNERS PA - JASPER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 MARVIN HANCOCK DR
JASPER TX
75951-4935
US

IV. Provider business mailing address

PO BOX 5188
LONGVIEW TX
75608-5188
US

V. Phone/Fax

Practice location:
  • Phone: 903-663-3600
  • Fax: 866-777-9502
Mailing address:
  • Phone: 903-663-3600
  • Fax: 866-777-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: HAROLD LEE BOLNICK
Title or Position: OWNER
Credential: M.D.
Phone: 903-261-7297