Basic Information
| Provider Information | |||||||||
| NPI: | 1104867936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLAND | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 405827 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303845827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012274068 | ||||||||
| FaxNumber: | 9012274051 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 BAPTIST BLVD | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622401412 | ||||||||
| FaxNumber: | 6622401949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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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 | 207RC0000X | 6387 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 056686 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 00027291 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 06387 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 730-73298 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 0115039 | 05 | MS | MEDICAID | 730-01754 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 730-05844 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 730-05954 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 009601740 | 05 | AL | MEDICAID |