Provider Demographics
NPI:1407846587
Name:BOLANOWSKI, PAUL J (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:BOLANOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1252
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07207-1252
Mailing Address - Country:US
Mailing Address - Phone:908-352-8110
Mailing Address - Fax:908-355-9583
Practice Address - Street 1:219 S BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-3453
Practice Address - Country:US
Practice Address - Phone:908-352-8110
Practice Address - Fax:908-355-9583
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA25753208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1553003Medicaid
NJ452587Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NJC55345Medicare UPIN