Provider Demographics
NPI:1700275823
Name:JEFFERY A BOLLENBACHER DO PSC
Entity Type:Organization
Organization Name:JEFFERY A BOLLENBACHER DO PSC
Other - Org Name:SPORTS ORTHOPEDICS PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHOPEDIC SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLLENBACHER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-234-4243
Mailing Address - Street 1:PO BOX 3402
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-0402
Mailing Address - Country:US
Mailing Address - Phone:812-234-4243
Mailing Address - Fax:812-478-3663
Practice Address - Street 1:3903 S 7TH ST STE 1A
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5710
Practice Address - Country:US
Practice Address - Phone:812-234-4243
Practice Address - Fax:812-478-3663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ02001578207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty