Basic Information
| Provider Information | |||||||||
| NPI: | 1134539471 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLAND | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331999 | ||||||||
| FaxNumber: | 9722333666 | ||||||||
| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885847888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2014 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 125-065680 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 036148562 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | S4602 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.