Provider Demographics
NPI:1891977294
Name:JOHN BOLDEN M.D. S.C.
Entity Type:Organization
Organization Name:JOHN BOLDEN M.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:708-349-0055
Mailing Address - Street 1:10660 W 143RD ST STE B
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1989
Mailing Address - Country:US
Mailing Address - Phone:708-349-0055
Mailing Address - Fax:708-460-8031
Practice Address - Street 1:114 W WAVERLY ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1422
Practice Address - Country:US
Practice Address - Phone:708-349-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106844207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDE2561OtherPALMETTO RR MEDICARE
IL03232029OtherBLUE CROSS BLUE SHIELD
IL036106844Medicaid
ILDE2561OtherPALMETTO RR MEDICARE