=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063659530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOLIVAR PHYSICIAN PRACTICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2009
-----------------------------------------------------
Last Update Date | 02/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 E SUNFLOWER RD SUITE 102
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38732-2830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-843-8885
-----------------------------------------------------
Fax | 662-843-2280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 907 E SUNFLOWER RD SUITE 102
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38732-2830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-843-8885
-----------------------------------------------------
Fax | 662-843-2280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/OFFICER
-----------------------------------------------------
Name | DAVID DILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-843-8885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------