Basic Information
Provider Information | |||||||||
NPI: | 1871569210 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLEY | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 S 2ND ST STE 4B | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 171012546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 S 2ND ST STE 4B | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 171012546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172318472 | ||||||||
FaxNumber: | 7172318490 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2006 | ||||||||
LastUpdateDate: | 01/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | MD426303 | PA | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 2080N0001X | MD426303 | PA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
ID | Type | State | Issuer | Description | 101301146 | 05 | PA |   | MEDICAID | 000000169311 | 01 | PA | GATEWAY | OTHER | 001740376 | 01 | PA | HIGHMARK | OTHER | 1086483 | 01 | PA | AETNA-HMO | OTHER | 2407344000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER |