Provider Demographics
NPI:1437135373
Name:BOLAND, ANTHONY BRADLEY (MD)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:BRADLEY
Last Name:BOLAND
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-2680
Mailing Address - Fax:601-815-4563
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-2680
Practice Address - Fax:601-815-4563
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD295492086S0129X
GA0444172086S0129X
WAMD000228692086S0129X
MS209792086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07188733Medicaid
TN100033107OtherPHP TENNCARE
4078780OtherAETNA
TN3153656OtherBLUECROSS OF TN
TN62178953301OtherJOHN DEERE HEALTHCARE
TN0140040322OtherCIGNA HMO
TN3740047OtherUNITED HEALTHCARE
GA00832917BMedicaid
AL009965915Medicaid
56812OtherFIRST HEALTH
MSP01189946OtherRAILROAD MEDICARE PTAN
TN3812941Medicaid
WA8490567Medicaid
WA8490567Medicaid
TN3153656OtherBLUECROSS OF TN
GA00832917BMedicaid
TN3812941Medicare ID - Type Unspecified
AL009965915Medicaid
TN3812941Medicaid
4078780OtherAETNA
GA330005116Medicare ID - Type UnspecifiedRAILROAD