Basic Information
| Provider Information | |||||||||
| NPI: | 1689665754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOLIVAR GENERAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WEST TENNESSEE HEALTHCARE BOLIVAR HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 650 NUCKOLLS RD | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380081532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316583100 | ||||||||
| FaxNumber: | 7316590259 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 NUCKOLLS RD | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380081532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316583100 | ||||||||
| FaxNumber: | 7316590259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315415000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 0000000062 | TN | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 044Z320 | 05 | TN | MEDICAID |