MEDICARE: DR. KEITH A. BOLES 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	207Q00000X	Family Medicine Physician	K2852	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	080176902	OTHER	TX	RR/MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8B5536	OTHER	TX	BLUE SHIELD
2	1119000-10	OTHER	TX	CSHCN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710946561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH A. BOLES M.D.

Provider Business Mailing Address
First Line	:	1600 PROVIDENCE DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76707-2261
Country	:	US
Telephone Number	:	254-313-4200
Fax Number	:	254-313-4326

Provider Business Practice Location Address
First Line	:	500 SOUTH JOHNSON DRIVE
Second Line	:
City	:	MCGREGOR
State	:	TX
Zip	:	76657
Country	:	US
Telephone Number	:	254-313-5200
Fax Number	:	254-313-4531

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

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	04/30/2013

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