Provider Demographics
NPI:1588785794
Name:BOLIVAR UROLOGY CLINIC, PA
Entity type:Organization
Organization Name:BOLIVAR UROLOGY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-846-9990
Mailing Address - Street 1:907 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2830
Mailing Address - Country:US
Mailing Address - Phone:662-846-9990
Mailing Address - Fax:
Practice Address - Street 1:907 E SUNFLOWER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2830
Practice Address - Country:US
Practice Address - Phone:662-846-9990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17441208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126078Medicaid
MS09016081Medicaid
MS1407887391OtherINDIVIDUAL PROVIDER NPI
MS09016081Medicaid
MS09016081Medicaid