Basic Information
| Provider Information | |||||||||
| NPI: | 1154566560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLGER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EAGLEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | EAGLEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194031829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105396000 | ||||||||
| FaxNumber: | 6105390785 | ||||||||
| Practice Location | |||||||||
| Address1: | 5800 RIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191281737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154839900 | ||||||||
| FaxNumber: | 2154874221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2008 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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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 | 2084P0800X | OS014902 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1024403780001 | 05 | PA | MEDICAID |