MEDICARE: BOLL MEDICAL, 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	332BC3200X	Customized Equipment (DME)	279779	WV
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	279779	WV
3	332BX2000X	Oxygen Equipment & Supplies (DME)	279779	WV
4	335E00000X	Prosthetic/Orthotic Supplier	279779	WV
5	332B00000X	Durable Medical Equipment & Medical Supplies	279779	WV

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
2	001705317	OTHER	WV	BLUE CROSS BLUE SHIELD PR
3	041242100	OTHER	WV	FEDERAL BLACK LUNG

General Provider Information

NPI Number	:	1669463105
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLL MEDICAL, INC

Provider Business Mailing Address
First Line	:	PO BOX 11810
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25339-1810
Country	:	US
Telephone Number	:	304-345-2944
Fax Number	:	304-345-2957

Provider Business Practice Location Address
First Line	:	1223 WASHINGTON ST E
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-1814
Country	:	US
Telephone Number	:	304-345-2944
Fax Number	:	304-345-2957

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. M. EUGENE WEEMS
Credential	:
Telephone Number	:	304-345-2944

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	01/14/2011

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Directions to “BOLL MEDICAL, INC ” Practice Location

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