Basic Information
| Provider Information | |||||||||
| NPI: | 1073589537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLING | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 598 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336706 | ||||||||
| FaxNumber: | 4786335384 | ||||||||
| Practice Location | |||||||||
| Address1: | 3780 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312060800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786335500 | ||||||||
| FaxNumber: | 4787843550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 003551 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100002808A | 05 | GA | MEDICAID |