Provider Demographics
NPI:1689665754
Name:BOLIVAR GENERAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:BOLIVAR GENERAL HOSPITAL, INC.
Other - Org Name:WEST TENNESSEE HEALTHCARE BOLIVAR HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-541-5000
Mailing Address - Street 1:650 NUCKOLLS RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1532
Mailing Address - Country:US
Mailing Address - Phone:731-658-3100
Mailing Address - Fax:731-659-0259
Practice Address - Street 1:650 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1532
Practice Address - Country:US
Practice Address - Phone:731-658-3100
Practice Address - Fax:731-659-0259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000062275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN044Z320Medicaid
TN044U181Medicaid