MEDICARE: DR. JOHN P BOLGER PH.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	103TA0700X	Adult Development & Aging Psychologist	4800	OH
2	103TC0700X	Clinical Psychologist	4800	OH
3	103TH0004X	Health Psychologist	4800	OH
4	103TR0400X	Rehabilitation Psychologist	4800	OH
5	103G00000X	Clinical Neuropsychologist	4800	OH

General Provider Information

NPI Number	:	1891725024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN P BOLGER PH.D.

Provider Business Mailing Address
First Line	:	1305 WILD OLIVE DR
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-7478
Country	:	US
Telephone Number	:	910-987-7285
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 WILD OLIVE DR
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-7478
Country	:	US
Telephone Number	:	910-987-7285
Fax Number	:

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	04/04/2019

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