Provider Demographics
NPI:1386648913
Name:BOLDT, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:BOLDT
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 1:1472 SOLUTIONS CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1004
Mailing Address - Country:US
Mailing Address - Phone:513-557-3333
Mailing Address - Fax:513-557-3332
Practice Address - Street 1:3131 QUEEN CITY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2316
Practice Address - Country:US
Practice Address - Phone:513-557-3333
Practice Address - Fax:513-557-3332
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2008-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350566555207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100328530Medicaid
KY04962038Medicaid
OH0974521Medicaid
OH0974521Medicaid
OH930019361Medicare PIN
KY04962038Medicaid