Provider Demographics
NPI:1659488807
Name:BOLAN, MICHAEL SHAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:BOLAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2272 32ND ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1509
Mailing Address - Country:US
Mailing Address - Phone:616-247-0399
Mailing Address - Fax:616-247-0499
Practice Address - Street 1:2272 32ND ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-1509
Practice Address - Country:US
Practice Address - Phone:616-247-0399
Practice Address - Fax:616-247-0499
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101009303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A76530Medicare UPIN