Basic Information
| Provider Information | |||||||||
| NPI: | 1639177595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLCH | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | JEFFERSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1326 EISENHOWER DR | ||||||||
| Address2: | BLDG. 2 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125275300 | ||||||||
| FaxNumber: | 9125275149 | ||||||||
| Practice Location | |||||||||
| Address1: | 1326 EISENHOWER DR | ||||||||
| Address2: | BLDG. 2 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125275300 | ||||||||
| FaxNumber: | 9125275149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
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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 | 207RC0000X | 016876 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000176712AA | 05 | GA | MEDICAID | 000176712R | 05 | GA | MEDICAID | 000932412A | 05 | GA | MEDICAID | 000932412B | 05 | GA | MEDICAID | G16876 | 05 | SC | MEDICAID | 060065859 | 01 | GA | RR MEDICARE | OTHER | 082552 | 01 | GA | BCBS | OTHER | 000176712Z | 05 | GA | MEDICAID | 000176712C | 05 | GA | MEDICAID |