Provider Demographics
NPI:1417941642
Name:BOLLINGER, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:BOLLINGER
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 1:555 PETALUMA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4225
Mailing Address - Country:US
Mailing Address - Phone:707-823-7602
Mailing Address - Fax:707-823-7625
Practice Address - Street 1:555 PETALUMA AVE
Practice Address - Street 2:STE B
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4225
Practice Address - Country:US
Practice Address - Phone:707-823-7602
Practice Address - Fax:707-823-7625
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65404207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A654040Medicaid
CA4616860001Medicare NSC
CAAQ191Medicare PIN
CA00A654040Medicare PIN
H61672Medicare UPIN