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Contact Information

RANDALL J BOLAR, MD
1027 WASHINGTON AVE
DETROIT LAKES, MN56501-3409
 Phone: 218-847-5611
 Fax: 218-847-0881
 Website:
 

Specialty

Taxonomy Code Specialty Code Provider Type

Surgery

208600000X 02 Physician/General Surgery
Indicates primary specialty

NPI Profile & details for RANDALL J BOLAR · (Male)

NPI Number 1558323246
Status Active
Credentials MD
Entity Individual
Enumeration date 04/06/2006
Last updated 12/23/2015 - About 10 years ago
Sole proprietor 1 No
Identifiers
  • MN License # 36945
  • TN License # 34949
  • KY Medicaid 64357130
  • MN Medicaid 1558323246
  • TN Medicaid 1515147
  • TN Medicaid 3338849
  • Other 10802394 CAQH
  • KY Other 7774037 AETNA
  • KY Other 000000069481 ANTHEM BC
  • TN Other TN0125 AMERICHOICE
  • TN Other 01281517 AMERIGROUP
  • TN Other 4221186 BCBS
  • TN Other 203500913011 TRICARE
Hospital affiliation(s)
  • ESSENTIA HEALTH FOSSTON - (Critical Access)
    900 HILLIGOSS BOULEVARD SE
    FOSSTON, MN 56542
  • ESSENTIA HEALTH ST MARYS - (Acute Care)
    1027 WASHINGTON AVE
    DETROIT LAKES, MN 56501
1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.

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