Provider Demographics
NPI:1639177595
Name:BOLCH, SIDNEY JEFFERSON III (MD)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:JEFFERSON
Last Name:BOLCH
Suffix:III
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 1:1326 EISENHOWER DR
Mailing Address - Street 2:BLDG. 2
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3928
Mailing Address - Country:US
Mailing Address - Phone:912-527-5300
Mailing Address - Fax:912-527-5149
Practice Address - Street 1:1326 EISENHOWER DR
Practice Address - Street 2:BLDG. 2
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3928
Practice Address - Country:US
Practice Address - Phone:912-527-5300
Practice Address - Fax:912-527-5149
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016876207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000176712AAMedicaid
GA000176712RMedicaid
GA000932412AMedicaid
GA000932412BMedicaid
SCG16876Medicaid
GA060065859OtherRR MEDICARE
GA082552OtherBCBS
GA000176712ZMedicaid
GA000176712CMedicaid
D44884Medicare UPIN
GA000932412AMedicaid