=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386769065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD A KULICH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 07/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 CORBIN PL #4S
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-617-2194
-----------------------------------------------------
Fax | 718-332-6459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 CORBIN PL #4S
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-617-2194
-----------------------------------------------------
Fax | 718-332-6459
-----------------------------------------------------
=====================================================
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 | ME97669
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 254048
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------