Organization
BOLIVAR UROLOGY CLINIC, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DEREK MILES MD (PRESIDENT)
(662) 846-9990
Entity
Organization
Contact information
Practice address
907 E SUNFLOWER RD, SUITE 103, CLEVELAND, MS 38732-2830
(662) 846-9990
Mailing address
907 E SUNFLOWER RD, SUITE 103, CLEVELAND, MS 38732-2830
(662) 846-9990
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
17441
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00126078
—
MS
05
—
09016081
—
MS
01
—
1407887391
INDIVIDUAL PROVIDER NPI
MS
Enumeration date
04/03/2007
Last updated
08/22/2020
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