Provider Demographics
NPI:1699733782
Name:BOLTON, GREGORY C JR (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:BOLTON
Suffix:JR
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:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:SKIPPACK
Mailing Address - State:PA
Mailing Address - Zip Code:19474-0195
Mailing Address - Country:US
Mailing Address - Phone:412-599-1039
Mailing Address - Fax:412-599-1035
Practice Address - Street 1:100 MARKET STREEET
Practice Address - Street 2:SUITE 300
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-4927
Practice Address - Country:US
Practice Address - Phone:412-599-1039
Practice Address - Fax:412-599-1035
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060356L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001707640Medicaid
PA001707640Medicaid
PA016577Medicare PIN