Healthcare Provider Details

I. General information

NPI: 1891820965
Provider Name (Legal Business Name): BOLANOWSKI SURGICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 S BROAD ST
ELIZABETH NJ
07202-3453
US

IV. Provider business mailing address

219 S BROAD ST
ELIZABETH NJ
07202-3453
US

V. Phone/Fax

Practice location:
  • Phone: 908-352-8110
  • Fax: 908-355-9583
Mailing address:
  • Phone: 908-352-8110
  • Fax: 908-355-9583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMA25753
License Number StateNJ

VIII. Authorized Official

Name: PAUL JP BOLANOWSKI
Title or Position: PRESIDENT
Credential: MD
Phone: 908-352-8110