Provider Demographics
NPI:1538634050
Name:BOLIVAR GENERAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:BOLIVAR GENERAL HOSPITAL, INC.
Other - Org Name:WEST TENNESSEE MEDICAL GROUP PRIMARY CARE BOLIVAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-512-1277
Mailing Address - Street 1:620 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3923
Mailing Address - Country:US
Mailing Address - Phone:731-512-1277
Mailing Address - Fax:731-984-2199
Practice Address - Street 1:640 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1532
Practice Address - Country:US
Practice Address - Phone:731-658-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOLIVAR GENERAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-11
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty