Provider Demographics
NPI:1467477711
Name:BOLANDER, JAMES E (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:BOLANDER
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 1:2608 LINCROFT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1918
Mailing Address - Country:US
Mailing Address - Phone:260-637-1317
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022680207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100374320Medicaid
IN930026563OtherRAILROAD
IN142520KMedicare ID - Type Unspecified
IN100374320Medicaid
IN138420BMedicare ID - Type Unspecified
IN178650BMedicare ID - Type Unspecified
D95285Medicare UPIN