Basic Information
Provider Information | |||||||||
NPI: | 1710946561 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLES | ||||||||
FirstName: | KEITH | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 PROVIDENCE DR | ||||||||
Address2: |   | ||||||||
City: | WACO | ||||||||
State: | TX | ||||||||
PostalCode: | 767072261 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2543134200 | ||||||||
FaxNumber: | 2543134326 | ||||||||
Practice Location | |||||||||
Address1: | 500 SOUTH JOHNSON DRIVE | ||||||||
Address2: |   | ||||||||
City: | MCGREGOR | ||||||||
State: | TX | ||||||||
PostalCode: | 76657 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2543135200 | ||||||||
FaxNumber: | 2543134531 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2006 | ||||||||
LastUpdateDate: | 04/30/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K2852 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8B5536 | 01 | TX | BLUE SHIELD | OTHER | 1119000-10 | 01 | TX | CSHCN | OTHER | 1119000-07 | 05 | TX |   | MEDICAID | 080176902 | 01 | TX | RR/MEDICARE | OTHER |