Provider Demographics
NPI:1891758512
Name:BOLISAY, ARNOLD GARCIA (MD)
Entity Type:Individual
Prefix:
First Name:ARNOLD
Middle Name:GARCIA
Last Name:BOLISAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7425 JANES AVE
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2356
Mailing Address - Country:US
Mailing Address - Phone:815-300-7764
Mailing Address - Fax:
Practice Address - Street 1:7425 JANES AVE
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2356
Practice Address - Country:US
Practice Address - Phone:153-007-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087183207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00268578OtherRAILROAD MEDICARE
IL036087183Medicaid
ILIL3596037OtherMEDICARE LOC 15 PIN
ILF77120Medicare UPIN
ILP00268578Medicare PIN
ILIL3596037OtherMEDICARE LOC 15 PIN
IL036087183Medicaid