Basic Information
| Provider Information | |||||||||
| NPI: | 1174103964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLEN | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 GILLHAM RD | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT DEPARTMENT | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167015200 | ||||||||
| FaxNumber: | 8163029939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 GILLHAM RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162343000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2021 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 94-10590 | KS | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 2021019657 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.