Provider Demographics
NPI:1558309757
Name:BOLLIS, ALEXANDER M (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:M
Last Name:BOLLIS
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:PO BOX 957415
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5551 WINGHAVEN BLVD
Practice Address - Street 2:SUITE 132
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3617
Practice Address - Country:US
Practice Address - Phone:636-695-2514
Practice Address - Fax:636-695-2526
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36068207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990009648OtherRAILROAD MEDICARE
MO201784709Medicaid
MO000008710Medicare PIN
MO990009648OtherRAILROAD MEDICARE