Provider Demographics
NPI:1821026683
Name:BOLAND, MARK S (DO FACOS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:BOLAND
Suffix:
Gender:M
Credentials:DO FACOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 SIR THOMAS CT
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4839
Mailing Address - Country:US
Mailing Address - Phone:717-541-8898
Mailing Address - Fax:717-541-0641
Practice Address - Street 1:840 SIR THOMAS CT
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4839
Practice Address - Country:US
Practice Address - Phone:717-541-8898
Practice Address - Fax:717-541-0641
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005543L2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA119358Medicare ID - Type Unspecified
C30671Medicare UPIN