MEDICARE: BOLANOWSKI SURGICAL GROUP 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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	MA25753	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891820965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLANOWSKI SURGICAL GROUP PC

Provider Business Mailing Address
First Line	:	219 S BROAD ST
Second Line	:
City	:	ELIZABETH
State	:	NJ
Zip	:	07202-3453
Country	:	US
Telephone Number	:	908-352-8110
Fax Number	:	908-355-9583

Provider Business Practice Location Address
First Line	:	219 S BROAD ST
Second Line	:
City	:	ELIZABETH
State	:	NJ
Zip	:	07202-3453
Country	:	US
Telephone Number	:	908-352-8110
Fax Number	:	908-355-9583

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PAUL JP BOLANOWSKI
Credential	:	MD
Telephone Number	:	908-352-8110

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	08/22/2020

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