=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043298052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GIRISH BULSARA MD FACP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2006
-----------------------------------------------------
Last Update Date | 03/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 GREENWAY EAST
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-849-7854
-----------------------------------------------------
Fax | 516-873-0786
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54 GREENWAY EAST
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-849-7854
-----------------------------------------------------
Fax | 516-873-0786
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | 196576
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------