Individual
RANDALL J. BOLAR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1027 WASHINGTON AVE, DETROIT LAKES, MN 56501-3409
(218) 847-5611
(218) 847-0881
Mailing address
1027 WASHINGTON AVE, DETROIT LAKES, MN 56501-3409
(218) 847-5611
(218) 847-0881
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
34949
TN
208600000X
Surgery Physician
Primary
36945
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000069481
ANTHEM BC
KY
01
—
01281517
AMERIGROUP
TN
01
—
10802394
CAQH
—
05
—
1515147
—
TN
05
—
1558323246
—
MN
01
—
203500913011
TRICARE
TN
05
—
3338849
—
TN
01
—
4221186
BCBS
TN
05
—
64357130
—
KY
01
—
7774037
AETNA
KY
01
—
TN0125
AMERICHOICE
TN
Enumeration date
04/06/2006
Last updated
12/23/2015
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