Basic Information
| Provider Information | |||||||||
| NPI: | 1437159217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLDRY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 550 RUSH CREEK PKWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640689608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164551155 | ||||||||
| FaxNumber: | 8164551161 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 RUSH CREEK PKWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640689608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164551155 | ||||||||
| FaxNumber: | 8164551161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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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 | 213E00000X | 000575 | MO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 12-00227 | KS | N | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 302817903 | 05 | MO | MEDICAID |