Basic Information
| Provider Information | |||||||||
| NPI: | 1558323246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLAR | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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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 | 208600000X | 34949 | TN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 36945 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1515147 | 05 | TN | MEDICAID | TN0125 | 01 | TN | AMERICHOICE | OTHER | 203500913011 | 01 | TN | TRICARE | OTHER | 000000069481 | 01 | KY | ANTHEM BC | OTHER | 10802394 | 01 | CAQH | OTHER | 1558323246 | 05 | MN | MEDICAID | 01281517 | 01 | TN | AMERIGROUP | OTHER | 4221186 | 01 | TN | BCBS | OTHER | 64357130 | 05 | KY | MEDICAID | 7774037 | 01 | KY | AETNA | OTHER | 3338849 | 05 | TN | MEDICAID |