Provider Demographics
NPI:1558850792
Name:BOLINGER, RICHARD A (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:BOLINGER
Suffix:
Gender:M
Credentials:PT
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 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-282-5435
Mailing Address - Fax:423-282-5767
Practice Address - Street 1:313 PRINCETON RD STE 3
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2000
Practice Address - Country:US
Practice Address - Phone:423-282-5435
Practice Address - Fax:423-282-5767
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ036781Medicaid