Provider Demographics
NPI:1568685287
Name:PRAVEEN BOLARUM, MD LLC
Entity Type:Organization
Organization Name:PRAVEEN BOLARUM, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:BOLARUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-694-6688
Mailing Address - Street 1:196 THOMAS JOHNSON DRIVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702
Mailing Address - Country:US
Mailing Address - Phone:301-694-6688
Mailing Address - Fax:301-694-8524
Practice Address - Street 1:196 THOMAS JOHNSON DRIVE
Practice Address - Street 2:SUITE 225
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:301-694-6688
Practice Address - Fax:301-694-8524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062223207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty