Provider Demographics
NPI:1063576130
Name:BOLEN, JOEL C (MD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:C
Last Name:BOLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 CARMICHAEL WAY
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-3671
Mailing Address - Country:US
Mailing Address - Phone:337-277-7665
Mailing Address - Fax:334-277-7142
Practice Address - Street 1:1230 CARMICHAEL WAY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3671
Practice Address - Country:US
Practice Address - Phone:334-277-7665
Practice Address - Fax:334-277-7142
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20157207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51021380OtherBLUE CROSS
AL000036956Medicaid
AL51036956OtherBCBSAL
ALG34364Medicare UPIN
AL000021380Medicare ID - Type Unspecified
AL000036956Medicare PIN