Provider Demographics
NPI:1851429971
Name:BOLTON CLINIC, PLLC
Entity Type:Organization
Organization Name:BOLTON CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:KROOSS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:601-932-3191
Mailing Address - Street 1:115 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MS
Mailing Address - Zip Code:39041
Mailing Address - Country:US
Mailing Address - Phone:601-866-7723
Mailing Address - Fax:601-866-7773
Practice Address - Street 1:2001 AIRPORT RD N
Practice Address - Street 2:SUITE 204
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8827
Practice Address - Country:US
Practice Address - Phone:601-932-3191
Practice Address - Fax:601-936-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR652075363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
253891Medicare Oscar/Certification