Provider Demographics
NPI:1386076800
Name:BOLIVAR PHYSICIAN PRACTICES LLC
Entity type:Organization
Organization Name:BOLIVAR PHYSICIAN PRACTICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:N
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:903 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2835
Mailing Address - Country:US
Mailing Address - Phone:662-545-3205
Mailing Address - Fax:662-545-3204
Practice Address - Street 1:903 E SUNFLOWER RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2835
Practice Address - Country:US
Practice Address - Phone:662-545-3205
Practice Address - Fax:662-545-3204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOLIVAR PHYSICIAN PRACTICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-07
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty