MEDICARE: JOHN J BOMALASKI MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VX0201X	Gynecologic Oncology Physician

General Provider Information

NPI Number	:	1174596167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN J BOMALASKI MD PA

Provider Business Mailing Address
First Line	:	PO BOX 560730
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32956-0730
Country	:	US
Telephone Number	:	321-752-0944
Fax Number	:	321-752-0756

Provider Business Practice Location Address
First Line	:	7000 SPYGLASS CT
Second Line	:	SUITE 300
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8288
Country	:	US
Telephone Number	:	321-752-0944
Fax Number	:	321-752-0756

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN J BOMALASKI
Credential	:	MD
Telephone Number	:	321-434-4656

Provider Enumeration Date	:	02/09/2006
Last Update Date	:	08/22/2020

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