Provider Demographics
NPI:1205881190
Name:JANARDHAN BOLLU MD PA
Entity type:Organization
Organization Name:JANARDHAN BOLLU MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANARDHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-754-9600
Mailing Address - Street 1:PO BOX 7107
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-7107
Mailing Address - Country:US
Mailing Address - Phone:973-754-9600
Mailing Address - Fax:
Practice Address - Street 1:32 HINE ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2955
Practice Address - Country:US
Practice Address - Phone:973-754-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA059857207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7135106Medicaid
NJ100305Medicare PIN
NJ7135106Medicaid