Basic Information
| Provider Information | |||||||||
| NPI: | 1306846076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLTON SMITH | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | ALLISON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7366 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563027366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202575595 | ||||||||
| FaxNumber: | 3202575596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1990 CONNECTICUT AVE S | ||||||||
| Address2: | |||||||||
| City: | SARTELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563772554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202575595 | ||||||||
| FaxNumber: | 3202575596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 46527 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2141654 | 01 | MN | ARAZ/ AMERICA'S PPO | OTHER | 16-03053 | 01 | MN | MEDICA | OTHER | 284L1BO | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 411772562 | 01 | MN | GREATWEST HEALTHCARE | OTHER | 965251040913 | 01 | MN | PREFERRED ONE | OTHER | 131470C561 | 01 | MN | UCARE OF MINNESOTA | OTHER | 411772562 | 01 | MN | TRICARE | OTHER | 492485100 | 05 | MN | MEDICAID | HP44741 | 01 | MN | HEALTH PARTNERS | OTHER |