Basic Information
| Provider Information | |||||||||
| NPI: | 1588692388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLTON | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | MANNING | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19134 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972800134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032455142 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6400 SE LAKE RD STE 325 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972222185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037861711 | ||||||||
| FaxNumber: | 5037869919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD20092 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 226895 | 01 | OR | OMAP PROVIDER # | OTHER |