Provider Demographics
NPI:1316388416
Name:BOLIVAR PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:BOLIVAR PHYSICIAN PRACTICES LLC
Other - Org Name:BOLIVAR UROLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:N
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-565-1508
Mailing Address - Street 1:907 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2830
Mailing Address - Country:US
Mailing Address - Phone:662-846-9990
Mailing Address - Fax:662-846-5444
Practice Address - Street 1:907 E SUNFLOWER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2830
Practice Address - Country:US
Practice Address - Phone:662-846-9990
Practice Address - Fax:662-846-5444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty