Organization
JOHN BOLDEN M.D. S.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN BOLDEN JR. M.D. (OWNER)
(708) 349-0055
Entity
Organization
Contact information
Practice address
114 W WAVERLY ST, MORRIS, IL 60450-1422
(708) 349-0055
Mailing address
10660 W 143RD ST STE B, ORLAND PARK, IL 60462-1989
(708) 349-0055
(708) 460-8031
Taxonomy
Speciality
Code
Description
License number
State
207RI0200X
Infectious Disease Physician
Primary
036106844
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03232029
BLUE CROSS BLUE SHIELD
IL
05
—
036106844
—
IL
01
—
DE2561
PALMETTO RR MEDICARE
IL
Enumeration date
11/28/2007
Last updated
02/03/2011
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