Basic Information
| Provider Information | |||||||||
| NPI: | 1609870583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLICK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572066 | ||||||||
| FaxNumber: | 4238572070 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 MEDICAL PARK BLVD | ||||||||
| Address2: | STE 3000 | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376207352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239902400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
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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 | 207Q00000X | MD 025833 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3085969 | 05 | TN | MEDICAID | 5644721 | 05 | VA | MEDICAID | 3085962 | 05 | TN | MEDICAID |