Provider Demographics
NPI:1457357543
Name:BOLIVAR ENT, INC
Entity Type:Organization
Organization Name:BOLIVAR ENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCARTHUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-843-8801
Mailing Address - Street 1:PO BOX 1389
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-1389
Mailing Address - Country:US
Mailing Address - Phone:662-843-8801
Mailing Address - Fax:
Practice Address - Street 1:907 E SUNFLOWER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2830
Practice Address - Country:US
Practice Address - Phone:662-843-8801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17632207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016120Medicaid