Provider Demographics
NPI:1063425486
Name:COLUMBUS CARDIOVASCULAR CARE PLLC
Entity type:Organization
Organization Name:COLUMBUS CARDIOVASCULAR CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-240-1412
Mailing Address - Street 1:255 BAPTIST BLVD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2011
Mailing Address - Country:US
Mailing Address - Phone:662-240-1412
Mailing Address - Fax:662-240-1949
Practice Address - Street 1:255 BAPTIST BLVD
Practice Address - Street 2:SUITE 402
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2011
Practice Address - Country:US
Practice Address - Phone:662-240-1412
Practice Address - Fax:662-240-1949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115039Medicaid
MS00115039Medicaid
MS00115039Medicaid
DF4818Medicare ID - Type UnspecifiedRAILROAD MEDICARE