Provider Demographics
NPI:1720157464
Name:TLC HEALTHCARE MEDICAL GROUP PC
Entity type:Organization
Organization Name:TLC HEALTHCARE MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOLHACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-670-0745
Mailing Address - Street 1:2850 NORTH COUNTRY CLUB ROAD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-1910
Mailing Address - Country:US
Mailing Address - Phone:520-322-6274
Mailing Address - Fax:520-509-4496
Practice Address - Street 1:5130 NORTH CIRCULO SOBRIO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6036
Practice Address - Country:US
Practice Address - Phone:520-670-0745
Practice Address - Fax:520-509-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QG0300X, 207R00000X, 207RG0300X
AZ20393207QG0300X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ328958Medicaid
AZ23969Medicare UPIN