MEDICARE: BOLIVAR ENT, INC

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	207Y00000X	Otolaryngology Physician	17632	MS

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

General Provider Information

NPI Number	:	1457357543
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLIVAR ENT, INC

Provider Business Mailing Address
First Line	:	PO BOX 1389
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-1389
Country	:	US
Telephone Number	:	662-843-8801
Fax Number	:

Provider Business Practice Location Address
First Line	:	907 E SUNFLOWER RD
Second Line	:	SUITE 104
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2830
Country	:	US
Telephone Number	:	662-843-8801
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PETER MCARTHUR
Credential	:	M.D.
Telephone Number	:	662-843-8801

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	03/25/2008

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Directions to “BOLIVAR ENT, INC ” Practice Location

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