MEDICARE: MR. JOHN N. BOLL JR. D.O.

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	207VX0000X	Obstetrics Physician	OS010395L	PA
2	207Q00000X	Family Medicine Physician	OS010395L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073516944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN N. BOLL JR. D.O.

Provider Business Mailing Address
First Line	:	1201 GRAMPIAN BLVD
Second Line	:
City	:	WILLIAMSPORT
State	:	PA
Zip	:	17701-1900
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 HIGH ST
Second Line	:	SUITE 4001
City	:	WILLIAMSPORT
State	:	PA
Zip	:	17701-3100
Country	:	US
Telephone Number	:	570-321-2345
Fax Number	:	570-321-2359

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	04/16/2021

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Directions to “ MR. JOHN N. BOLL JR. D.O.” Practice Location

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