Healthcare Provider Details

I. General information

NPI: 1386769065
Provider Name (Legal Business Name): EDWARD A KULICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CORBIN PL #4S
BROOKLYN NY
11235-4946
US

IV. Provider business mailing address

200 CORBIN PL #4S
BROOKLYN NY
11235-4946
US

V. Phone/Fax

Practice location:
  • Phone: 917-617-2194
  • Fax: 718-332-6459
Mailing address:
  • Phone: 917-617-2194
  • Fax: 718-332-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME97669
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number254048
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: