MEDICARE: BOLIVAR MONROY JR.

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	163W00000X	Registered Nurse	664942	NY

General Provider Information

NPI Number	:	1538695077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BOLIVAR MONROY JR.

Provider Business Mailing Address
First Line	:	712 LOGAN AVENUE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465
Country	:	US
Telephone Number	:	347-419-4800
Fax Number	:

Provider Business Practice Location Address
First Line	:	712 LOGAN AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465-2329
Country	:	US
Telephone Number	:	347-419-4800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2017
Last Update Date	:	05/03/2017

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