MEDICARE: EDWARD BOLT

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	225100000X	Physical Therapist	PT012047	GA

General Provider Information

NPI Number	:	1215313630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD BOLT

Provider Business Mailing Address
First Line	:	PO BOX 949
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30162-0949
Country	:	US
Telephone Number	:	706-234-9317
Fax Number	:

Provider Business Practice Location Address
First Line	:	212 RETREAT VLG STE 212
Second Line	:
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-2403
Country	:	US
Telephone Number	:	912-638-1444
Fax Number	:	912-638-0077

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

Provider Enumeration Date	:	08/07/2015
Last Update Date	:	01/30/2018

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Directions to “ EDWARD BOLT ” Practice Location

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