Provider Demographics
NPI:1780335950
Name:BOLGER, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BOLGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 CHELMSFORD SQ N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1918
Mailing Address - Country:US
Mailing Address - Phone:786-734-7115
Mailing Address - Fax:
Practice Address - Street 1:6020 GROVEPORT RD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-1005
Practice Address - Country:US
Practice Address - Phone:614-505-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002977175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist