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General NPI Number Information
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NPI Number | 1558323246
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Entity Type | Individual
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Provider Name | RANDALL J. BOLAR M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/06/2006
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Last Update Date | 12/23/2015
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Provider Practice Location Address
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Address Line | 1027 WASHINGTON AVE
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City | DETROIT LAKES
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State | MN
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Zip | 56501-3409
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Country | US
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Telephone | 218-847-5611
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Fax | 218-847-0881
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Provider Business Mailing Address
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Address Line | 1027 WASHINGTON AVE
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City | DETROIT LAKES
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State | MN
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Zip | 56501-3409
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Country | US
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Telephone | 218-847-5611
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Fax | 218-847-0881
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 34949
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 36945
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License Number State | MN
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