Basic Information
| Provider Information | |||||||||
| NPI: | 1295738086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLAND | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENDRICKS | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 15849 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314162549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126914200 | ||||||||
| FaxNumber: | 9126914209 | ||||||||
| Practice Location | |||||||||
| Address1: | 1326 EISENHOWER DR | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126914200 | ||||||||
| FaxNumber: | 9126914209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 032397 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000457245C | 05 | GA | MEDICAID | G32397 | 05 | SC | MEDICAID |