MEDICARE: GABRIELA T BOLIN MD

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	208000000X	Pediatrics Physician	MD 29729	TN

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	:	1881688661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELA T BOLIN MD

Provider Business Mailing Address
First Line	:	881 PROFESSIONAL PARK DR
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37040-5257
Country	:	US
Telephone Number	:	931-645-4685
Fax Number	:	931-245-2117

Provider Business Practice Location Address
First Line	:	881 PROFESSIONAL PARK DR
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37040-5257
Country	:	US
Telephone Number	:	931-645-4685
Fax Number	:	931-245-2117

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	06/29/2020

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