Provider Demographics
NPI:1629505193
Name:BOLOIS, MARK ANDREW
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:BOLOIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8350 SHADY LANE DR
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-1638
Mailing Address - Country:US
Mailing Address - Phone:330-715-7671
Mailing Address - Fax:
Practice Address - Street 1:6694 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OH
Practice Address - Zip Code:44216-9201
Practice Address - Country:US
Practice Address - Phone:330-825-5202
Practice Address - Fax:234-678-6919
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH143671164W00000X
OHRN.470099163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1821411273Medicaid