Provider Demographics
NPI:1720297708
Name:BOLIVAR MEDICAL CLINIC
Entity Type:Organization
Organization Name:BOLIVAR MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-658-7111
Mailing Address - Street 1:610 NUCKOLLS RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1532
Mailing Address - Country:US
Mailing Address - Phone:731-658-7111
Mailing Address - Fax:731-658-4328
Practice Address - Street 1:610 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1532
Practice Address - Country:US
Practice Address - Phone:731-658-7111
Practice Address - Fax:731-658-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3720190Medicaid
TN2006653OtherBLUECROSS BLUESHIELD
TN3720190Medicaid