=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548056054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN WILLIAM BOLDT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2025
-----------------------------------------------------
Last Update Date | 04/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1108 NORTHVIEW DR
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45133-1184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-393-5781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 678 8 MILE RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45255-4623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-304-0430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------