Provider Demographics
NPI:1730160573
Name:BOLHACK, SCOTT M (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:BOLHACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2850 NORTH COUNTRY CLUB ROAD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-1910
Mailing Address - Country:US
Mailing Address - Phone:520-322-6274
Mailing Address - Fax:520-509-4496
Practice Address - Street 1:5130 NORTH CIRCULO SOBRIO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6036
Practice Address - Country:US
Practice Address - Phone:520-670-0745
Practice Address - Fax:520-509-4496
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20393207RG0300X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ383612Medicaid
AZ23473Medicare ID - Type Unspecified
AZF29969Medicare UPIN
AZ383612Medicaid