Provider Demographics
NPI:1164790531
Name:SAMUEL F. BOLES MD PC
Entity Type:Organization
Organization Name:SAMUEL F. BOLES MD PC
Other - Org Name:ANNE ARUNDEL EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:BOLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-224-2010
Mailing Address - Street 1:PO BOX 62084
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2084
Mailing Address - Country:US
Mailing Address - Phone:443-481-6524
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:127 LUBRANO DR
Practice Address - Street 2:SUITE 301
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7114
Practice Address - Country:US
Practice Address - Phone:410-224-2010
Practice Address - Fax:410-224-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD226611300Medicaid