Healthcare Provider Details

I. General information

NPI: 1629117239
Provider Name (Legal Business Name): JAY B BOSNIAK MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 PAVILION AVE
LONG BRANCH NJ
07740-6415
US

IV. Provider business mailing address

143 PAVILION AVE
LONG BRANCH NJ
07740-6415
US

V. Phone/Fax

Practice location:
  • Phone: 732-229-7440
  • Fax: 732-229-2149
Mailing address:
  • Phone: 732-229-7440
  • Fax: 732-229-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number25MA02566100
License Number StateNJ

VIII. Authorized Official

Name: DR. JAY B BOSNIAK
Title or Position: CEO
Credential: MD
Phone: 732-229-7440