MEDICARE: CRISPIN G. BOLISAY, MD APMC

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	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1124217872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRISPIN G. BOLISAY, MD APMC

Provider Business Mailing Address
First Line	:	105 MEDICAL CENTER DR
Second Line	:	SUITE 304
City	:	SLIDELL
State	:	LA
Zip	:	70461-5544
Country	:	US
Telephone Number	:	985-646-0360
Fax Number	:	985-646-0362

Provider Business Practice Location Address
First Line	:	1340 POYDRAS ST
Second Line	:	SUITE 1850
City	:	NEW ORLEANS
State	:	LA
Zip	:	70112-1221
Country	:	US
Telephone Number	:	504-679-9901
Fax Number	:	504-679-9928

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CRISPIN G. BOLISAY
Credential	:	MD
Telephone Number	:	985-646-0360

Provider Enumeration Date	:	10/18/2007
Last Update Date	:	12/30/2008

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