Provider Demographics
NPI:1376508093
Name:BOLIN, BRENT L (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:L
Last Name:BOLIN
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7926 PRESTON HWY STE 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-964-4357
Practice Address - Fax:502-966-5948
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000052154BOtherHUMANA / NMA
1171473OtherPASSPORT / NMA
000000350677OtherANTHEM / NMA
9034053002OtherCIGNA / NMA
012961OtherSIHO / NMA
2440810000OtherPASSPORT ADVANTAGE
1183574OtherCHA / NMA
KY64012024Medicaid
9034053002OtherCIGNA / NMA
1183574OtherCHA / NMA