Provider Demographics
NPI:1124217872
Name:CRISPIN G. BOLISAY, MD APMC
Entity Type:Organization
Organization Name:CRISPIN G. BOLISAY, MD APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRISPIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOLISAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-646-0360
Mailing Address - Street 1:105 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5544
Mailing Address - Country:US
Mailing Address - Phone:985-646-0360
Mailing Address - Fax:985-646-0362
Practice Address - Street 1:1340 POYDRAS ST
Practice Address - Street 2:SUITE 1850
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1221
Practice Address - Country:US
Practice Address - Phone:504-679-9901
Practice Address - Fax:504-679-9928
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRISPIN G. BOLISAY, MD APMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-18
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4591040001Medicare NSC