MEDICARE: DR. CHANNING C BOLICK DC, MS

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	111N00000X	Chiropractor	2398	SC
2	111NI0013X	Independent Medical Examiner Chiropractor	CH7882	FL
3	111N00000X	Chiropractor	6191	GA
4	111N00000X	Chiropractor	CH7882	FL
5	111NX0100X	Occupational Health Chiropractor	CH7882	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	350050297	OTHER	FL	RAILROAD MEDICARE
9	K1903	OTHER	FL	MEDICARE GROUP NUMBER
13	544703	OTHER		WELLCARE/STAYWELL MEDICARE & MEDICAID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH7882	OTHER	FL	STATE LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	4573235	OTHER	FL	GHI PROVIDER NUMBER
5	1455405	OTHER	FL	CIGNA PROVIDER NUMBER
6	53988	OTHER	FL	ASHLINK PIN
7	55996	OTHER	FL	BLUE CROSS NUMBER
8	945833	OTHER	FL	PPNI PROVIDER NUMBER
10	P10000175970	OTHER	FL	SUNSHINE STATE
11	10728811	OTHER		CAQH NUMBER
12	332352	OTHER	FL	AVMED PROVIDER NUMBER

General Provider Information

NPI Number	:	1316936206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHANNING C BOLICK DC, MS

Provider Business Mailing Address
First Line	:	500 E HORATIO AVE STE 5
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7310
Country	:	US
Telephone Number	:	407-629-5333
Fax Number	:	407-629-5343

Provider Business Practice Location Address
First Line	:	500 E HORATIO AVE STE 5
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7310
Country	:	US
Telephone Number	:	407-629-5333
Fax Number	:	407-629-5343

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

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	09/23/2025

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