Provider Demographics
NPI:1104395243
Name:PRAVEEN BOLARUM, MD LLC
Entity Type:Organization
Organization Name:PRAVEEN BOLARUM, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOLARUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-694-6688
Mailing Address - Street 1:3390 URBANA PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7769
Mailing Address - Country:US
Mailing Address - Phone:301-694-6688
Mailing Address - Fax:
Practice Address - Street 1:3390 URBANA PIKE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7769
Practice Address - Country:US
Practice Address - Phone:301-810-5415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-19
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408672400Medicaid