Provider Demographics
NPI:1679530398
Name:BOLENE, JIM (MD)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:BOLENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:ANDREW
Other - Last Name:BOLENE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4500 S GARNETT RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5238
Mailing Address - Country:US
Mailing Address - Phone:918-728-6145
Mailing Address - Fax:
Practice Address - Street 1:3500 E FRANK PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2411
Practice Address - Country:US
Practice Address - Phone:918-333-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK153572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100089780AMedicaid
TX194934902Medicaid
NM89305078Medicaid
KS200664160AMedicaid
160551100OtherFIRSTCARE
TX8BD830OtherBCBSTX
E71457Medicare UPIN
KS200664160AMedicaid
OK100089780AMedicaid