=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861575458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOLGER FAMILY MEDICINE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 12/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 MEDICAL PLAZA PL
-----------------------------------------------------
City | MINDEN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71055-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-377-7118
-----------------------------------------------------
Fax | 318-377-7392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 MEDICAL PLAZA PL
-----------------------------------------------------
City | MINDEN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71055-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-377-7118
-----------------------------------------------------
Fax | 318-377-7392
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH EDWARD BOLGER
-----------------------------------------------------
Credential | M.D., PHD
-----------------------------------------------------
Telephone | 318-377-7118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 14517R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------