Basic Information
| Provider Information | |||||||||
| NPI: | 1700846722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLDEN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702145681 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708087399 | ||||||||
| FaxNumber: | 5708085942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD423426 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD423426 | PA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RH0002X | MD423426 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 867633 | 01 | PA | MEDICARE GROUP # | OTHER | 100000222 0003 0004 | 05 | PA | MEDICAID | 001582999 | 01 | PA | HIGHMARK BS | OTHER | 1007307260034 | 01 | PA | MEDICAID GROUP # | OTHER | 1010002220001 | 05 | PA | MEDICAID |