MEDICARE: JOHN BOLLENBACHER CRNA

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	367500000X	Certified Registered Nurse Anesthetist	086417	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00100713	OTHER	MO	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	184883	OTHER	MO	BCBS

General Provider Information

NPI Number	:	1952380792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN BOLLENBACHER CRNA

Provider Business Mailing Address
First Line	:	2140 AUTUMN RD
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-2703
Country	:	US
Telephone Number	:	573-686-5550
Fax Number	:	573-686-2139

Provider Business Practice Location Address
First Line	:	219 PHYSICIANS PARK
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-3956
Country	:	US
Telephone Number	:	573-686-5550
Fax Number	:

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

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	04/04/2008

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