MEDICARE: DR. GEORGE DADO BOLLOZOS 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	291U00000X	Clinical Medical Laboratory	33057	MO

General Provider Information

NPI Number	:	1235319906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE DADO BOLLOZOS M.D.

Provider Business Mailing Address
First Line	:	2040 CONCOURSE DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4119
Country	:	US
Telephone Number	:	314-872-7149
Fax Number	:	314-872-7155

Provider Business Practice Location Address
First Line	:	2040 CONCOURSE DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4119
Country	:	US
Telephone Number	:	314-872-7149
Fax Number	:	314-872-7155

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

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	11/09/2007

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