Provider Demographics
NPI:1598959389
Name:BOLA ELEMUREN MD. PA
Entity Type:Organization
Organization Name:BOLA ELEMUREN MD. PA
Other - Org Name:FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IYABO
Authorized Official - Middle Name:BOLA
Authorized Official - Last Name:ELEMUREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-699-8521
Mailing Address - Street 1:740 S AMY LN
Mailing Address - Street 2:STE 101
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-1343
Mailing Address - Country:US
Mailing Address - Phone:254-699-8521
Mailing Address - Fax:254-699-8528
Practice Address - Street 1:740 S AMY LN
Practice Address - Street 2:STE 101
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1343
Practice Address - Country:US
Practice Address - Phone:254-699-8521
Practice Address - Fax:254-699-8528
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOLA ELEMUREN MD.PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-05
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4050207Q00000X
TXPA01547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG88686Medicare UPIN