Provider Demographics
NPI:1083695530
Name:BULANOWSKI, JILL M (MPT)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:M
Last Name:BULANOWSKI
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7501
Mailing Address - Country:US
Mailing Address - Phone:631-424-2070
Mailing Address - Fax:631-935-1376
Practice Address - Street 1:675 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-7501
Practice Address - Country:US
Practice Address - Phone:631-424-2070
Practice Address - Fax:631-935-1376
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY176042POtherHIP HEALTH PLAN ID #
NY4137123OtherCIGNA ID #
NY6605483OtherGHI ID #
NY7796390OtherAETNA ID#
NY7796390OtherAETNA ID#