MEDICARE: ELENA BOLAND M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208C00000X	Colon & Rectal Surgery Physician	272375	NY
2	208600000X	Surgery Physician	272375	NY

General Provider Information

NPI Number	:	1063536886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELENA BOLAND M.D.

Provider Business Mailing Address
First Line	:	10 KELLOGG CT
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-4314
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 CORNELIA ST STE 102
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-2306
Country	:	US
Telephone Number	:	518-561-6410
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	10/02/2013

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