MEDICARE: MISS TATIANA BULANOV PT

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	225100000X	Physical Therapist	020707-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	020707-1	OTHER	NY	STATE LICENSE

General Provider Information

NPI Number	:	1982761375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TATIANA BULANOV PT

Provider Business Mailing Address
First Line	:	2543 E 11TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5011
Country	:	US
Telephone Number	:	917-882-0550
Fax Number	:

Provider Business Practice Location Address
First Line	:	2148 OCEAN AVE STE 301
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-1406
Country	:	US
Telephone Number	:	718-872-7002
Fax Number	:

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/21/2022

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