Provider Demographics
NPI:1639136377
Name:BOLT, THOMAS RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RICHARD
Last Name:BOLT
Suffix:
Gender:M
Credentials:MD
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 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:9313 MEDICAL PLAZA DRIVE
Practice Address - Street 2:STE 202
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-572-1200
Practice Address - Fax:843-553-0424
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC109910Medicaid
SC080093457OtherMEDICARE RAIL ROAD #
SCAA67507126Medicare PIN
SC080093457OtherMEDICARE RAIL ROAD #
SCB92259Medicare UPIN
SCAA67507555Medicare PIN
SCAA67507499Medicare PIN