Healthcare Provider Details

I. General information

NPI: 1841297249
Provider Name (Legal Business Name): MICHAEL ANTHONY BULANOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240B W MONTAUK HWY
HAMPTON BAYS NY
11946-3510
US

IV. Provider business mailing address

240B W MONTAUK HWY
HAMPTON BAYS NY
11946-3510
US

V. Phone/Fax

Practice location:
  • Phone: 631-728-7400
  • Fax: 631-728-7878
Mailing address:
  • Phone: 631-728-7400
  • Fax: 631-728-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number152718
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: