Provider Demographics
NPI:1629117239
Name:JAY B BOSNIAK MD PA
Entity Type:Organization
Organization Name:JAY B BOSNIAK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOSNIAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-229-7440
Mailing Address - Street 1:143 PAVILION AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-6415
Mailing Address - Country:US
Mailing Address - Phone:732-229-7440
Mailing Address - Fax:732-229-2149
Practice Address - Street 1:143 PAVILION AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6415
Practice Address - Country:US
Practice Address - Phone:732-229-7440
Practice Address - Fax:732-229-2149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02566100173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty