Basic Information
| Provider Information | |||||||||
| NPI: | 1548237993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLIN | ||||||||
| FirstName: | DELMAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 W CALHOUN ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241533836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407721890 | ||||||||
| FaxNumber: | 5407721893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 0101233203 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010054427 | 05 | VA | MEDICAID |