Provider Demographics
NPI:1720402175
Name:BOLIVAR OB/GYN
Entity Type:Organization
Organization Name:BOLIVAR OB/GYN
Other - Org Name:BOLIVAR OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:VOLCKO
Authorized Official - Suffix:
Authorized Official - Credentials:MT(ASCP) CSC, COBGC
Authorized Official - Phone:417-777-8131
Mailing Address - Street 1:1165 N BUTTERFIELD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1056
Mailing Address - Country:US
Mailing Address - Phone:417-777-8131
Mailing Address - Fax:417-777-8892
Practice Address - Street 1:1165 N BUTTERFIELD RD
Practice Address - Street 2:SUITE B
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1056
Practice Address - Country:US
Practice Address - Phone:417-777-8131
Practice Address - Fax:417-777-8892
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIGNATURE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013021740207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty