Provider Demographics
NPI:1982660155
Name:BOLLMANN, KERILYN (MD)
Entity Type:Individual
Prefix:DR
First Name:KERILYN
Middle Name:
Last Name:BOLLMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KERILYN
Other - Middle Name:
Other - Last Name:GWISDALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11250 N TATUM BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-2306
Mailing Address - Country:US
Mailing Address - Phone:480-460-8485
Mailing Address - Fax:480-504-0520
Practice Address - Street 1:11250 N TATUM BLVD STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-2306
Practice Address - Country:US
Practice Address - Phone:480-460-8485
Practice Address - Fax:480-504-0520
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25919207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ457673Medicaid
AZ457673Medicaid
Z122304Medicare PIN
Z77107Medicare PIN