Basic Information
| Provider Information | |||||||||
| NPI: | 1093784555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLEN | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12510 PROSPERITY DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209041663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404855200 | ||||||||
| FaxNumber: | 3016256906 | ||||||||
| Practice Location | |||||||||
| Address1: | 10215 FERNWOOD RD | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208171106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014935210 | ||||||||
| FaxNumber: | 3014935479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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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 | 207RG0100X | D0034069 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | D0034069 | 01 | MD | STATE LICENSE | OTHER |