Provider Demographics
NPI:1316902737
Name:BOLISAY, CRISPIN G (MD)
Entity type:Individual
Prefix:
First Name:CRISPIN
Middle Name:G
Last Name:BOLISAY
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:105 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5544
Mailing Address - Country:US
Mailing Address - Phone:985-646-0360
Mailing Address - Fax:985-646-0362
Practice Address - Street 1:105 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 304
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5544
Practice Address - Country:US
Practice Address - Phone:985-646-0360
Practice Address - Fax:985-646-0362
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2008-12-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA05389R207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1313491Medicaid
LA1313491Medicaid
LA50847CC11Medicare PIN
B89382Medicare UPIN