MEDICARE: BOULEVARD ANESTHESIA ASSOCIATES, PC

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	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1295770196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOULEVARD ANESTHESIA ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	255 W MICHIGAN AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-2218
Country	:	US
Telephone Number	:	517-787-6440
Fax Number	:	517-787-4146

Provider Business Practice Location Address
First Line	:	9002 QUEENS BLVD
Second Line	:
City	:	ELMHURST
State	:	NY
Zip	:	11373-4941
Country	:	US
Telephone Number	:	517-787-6440
Fax Number	:	517-787-4146

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	STUART WOLLMAN
Credential	:	M.D.
Telephone Number	:	718-558-1870

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	08/22/2020

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