Provider Demographics
NPI:1043454655
Name:BOLIVAR PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:BOLIVAR PHYSICIAN PRACTICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:N
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:429 W AIRLINE HWY
Mailing Address - Street 2:STE N
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-3817
Mailing Address - Country:US
Mailing Address - Phone:986-652-5052
Mailing Address - Fax:985-665-2191
Practice Address - Street 1:810 E SUNFLOWER RD
Practice Address - Street 2:STE. 100A
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2800
Practice Address - Country:US
Practice Address - Phone:662-843-8885
Practice Address - Fax:662-843-2280
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEPOINT HOSPITALS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-27
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G700497Medicare PIN