Provider Demographics
NPI:1174635924
Name:BOLAND, THOMAS S (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:BOLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MIFFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503
Mailing Address - Country:US
Mailing Address - Phone:570-342-3145
Mailing Address - Fax:570-344-1309
Practice Address - Street 1:200 MIFFLIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503
Practice Address - Country:US
Practice Address - Phone:570-342-3145
Practice Address - Fax:570-344-1309
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050762L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BO196826OtherHIGH MARK BLUE SHIELD
180035485OtherRAILROAD MEDICARE
42487OtherGEISINGER HEALTH PLAN
506554OtherAETNA
808091OtherFIRST PRIORITY HEALTH
PA001735395Medicaid
PA022271Medicare ID - Type Unspecified
PA001735395Medicaid