Provider Demographics
NPI:1285819516
Name:J. BLAKE BOLIN, M.D., P.A.
Entity Type:Organization
Organization Name:J. BLAKE BOLIN, M.D., P.A.
Other - Org Name:J. BLAKE BOLIN, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING REP
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:214-551-5101
Mailing Address - Street 1:3550 PARKWOOD BLVD
Mailing Address - Street 2:STE 405
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-1903
Mailing Address - Country:US
Mailing Address - Phone:469-287-8800
Mailing Address - Fax:469-287-8801
Practice Address - Street 1:3550 PARKWOOD BLVD
Practice Address - Street 2:STE 405
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-1903
Practice Address - Country:US
Practice Address - Phone:469-287-8800
Practice Address - Fax:469-287-8801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J. BLAKE BOLIN, M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-06
Last Update Date:2008-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8014174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1174563043OtherTYPE 1 NPI
TXH05483Medicare UPIN
TX1174563043OtherTYPE 1 NPI