Provider Demographics
NPI:1891820965
Name:BOLANOWSKI SURGICAL GROUP PC
Entity Type:Organization
Organization Name:BOLANOWSKI SURGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JP
Authorized Official - Last Name:BOLANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-352-8110
Mailing Address - Street 1:219 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-3453
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA25753208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1553003Medicaid
NJ1553003Medicaid