Provider Demographics
NPI:1558535419
Name:MICHAEL T. BOLLINGER, MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL T. BOLLINGER, MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-823-7602
Mailing Address - Street 1:555 PETALUMA AVE STE B
Mailing Address - Street 2:
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 STE B
Practice Address - Street 2:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65404174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A654040Medicaid
CA00A654040Medicare PIN
CAH61672Medicare UPIN
6319130001Medicare NSC
CA00A654040Medicaid