Provider Demographics
NPI:1811178577
Name:BOLTON FAMILY MEDICAL CLINIC, P.C.
Entity type:Organization
Organization Name:BOLTON FAMILY MEDICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-869-0033
Mailing Address - Street 1:PO BOX 1308
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-1308
Mailing Address - Country:US
Mailing Address - Phone:662-869-0033
Mailing Address - Fax:662-869-0053
Practice Address - Street 1:2781 HIGHWAY 145
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-9783
Practice Address - Country:US
Practice Address - Phone:662-869-0033
Practice Address - Fax:662-869-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09623207Medicaid
MSG97461Medicare UPIN
MS080003801Medicare PIN