Provider Demographics
NPI:1265497671
Name:CRISPIN G. BOLISAY, MD APMC
Entity type:Organization
Organization Name:CRISPIN G. BOLISAY, MD APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRISPIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOLISAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-646-0360
Mailing Address - Street 1:105 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5544
Mailing Address - Country:US
Mailing Address - Phone:985-646-0360
Mailing Address - Fax:985-646-0362
Practice Address - Street 1:105 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 304
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5544
Practice Address - Country:US
Practice Address - Phone:985-646-0360
Practice Address - Fax:985-646-0362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1443476Medicaid
LA5CC11Medicare ID - Type UnspecifiedGROUP MEDICARE #