Provider Demographics
NPI:1780165738
Name:PRAVEEN BOLARUM, MD LLC
Entity type:Organization
Organization Name:PRAVEEN BOLARUM, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOLARUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-694-6688
Mailing Address - Street 1:196 THOMAS JOHNSON DR STE 135
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4518
Mailing Address - Country:US
Mailing Address - Phone:561-283-1606
Mailing Address - Fax:
Practice Address - Street 1:23310 FREDERICK RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-9704
Practice Address - Country:US
Practice Address - Phone:561-283-1606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-28
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD590012300Medicaid