Provider Demographics
NPI:1912274192
Name:MICHAEL A BOLOGNESE MD PC
Entity Type:Organization
Organization Name:MICHAEL A BOLOGNESE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BOLOGNESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-530-1166
Mailing Address - Street 1:10215 FERNWOOD RD
Mailing Address - Street 2:SUITE 40
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-1106
Mailing Address - Country:US
Mailing Address - Phone:301-530-1166
Mailing Address - Fax:
Practice Address - Street 1:10215 FERNWOOD RD
Practice Address - Street 2:SUITE 40
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1106
Practice Address - Country:US
Practice Address - Phone:301-530-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD24234207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD101563Medicare PIN