Provider Demographics
NPI:1689814113
Name:MICHAEL E. BOLT, MD, LLC
Entity Type:Organization
Organization Name:MICHAEL E. BOLT, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BOLT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-421-6767
Mailing Address - Street 1:2410 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PARSONS
Mailing Address - State:KS
Mailing Address - Zip Code:67357-2747
Mailing Address - Country:US
Mailing Address - Phone:620-421-6767
Mailing Address - Fax:620-421-6766
Practice Address - Street 1:2410 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:PARSONS
Practice Address - State:KS
Practice Address - Zip Code:67357-2747
Practice Address - Country:US
Practice Address - Phone:620-421-6767
Practice Address - Fax:620-421-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200362160AMedicaid
KS200362160AMedicaid