Provider Demographics
NPI:1104867936
Name:BOLAND, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BOLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:901-227-4068
Mailing Address - Fax:901-227-4051
Practice Address - Street 1:255 BAPTIST BLVD
Practice Address - Street 2:SUITE 402
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705
Practice Address - Country:US
Practice Address - Phone:662-240-1412
Practice Address - Fax:662-240-1949
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS6387207RC0000X
GA056686207RC0000X
AL00027291207RC0000X
MS06387207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL730-73298OtherBLUE CROSS BLUE SHIELD
MS0115039Medicaid
AL730-01754OtherBLUE CROSS BLUE SHIELD
AL730-05844OtherBLUE CROSS BLUE SHIELD
AL730-05954OtherBLUE CROSS BLUE SHIELD
AL009601740Medicaid
AL730-05954OtherBLUE CROSS BLUE SHIELD
AL730-01754OtherBLUE CROSS BLUE SHIELD