Provider Demographics
NPI:1366494270
Name:BOLMER, AMY G (DO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:G
Last Name:BOLMER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 DEPT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-3630
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:510 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1964
Practice Address - Country:US
Practice Address - Phone:906-632-6013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013135207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI36-00041OtherPHP
MI36-70041OtherPHP FAMILY CARE
MI383267121OtherPHCS
MI383267121OtherPPOM
MI7541326OtherAETNA
MIP00122957OtherRAILROAD MEDICARE
MI4530050Medicaid
MI1153310564OtherBCBS/BCN
MI383267121OtherSPHN
MI200000001266OtherPHYSICIANS HEALTH PLAN
MI1009476OtherMCLAREN HEALTH ADVANTAGE
MI36-70041OtherPHP FAMILY CARE
MI7541326OtherAETNA