Basic Information
| Provider Information | |||||||||
| NPI: | 1063708600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLANOS | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 JFK DR STE 320 | ||||||||
| Address2: | |||||||||
| City: | ATLANTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334626641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615484900 | ||||||||
| FaxNumber: | 5614345165 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 JFK DR STE 320 | ||||||||
| Address2: | |||||||||
| City: | ATLANTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334626641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615484900 | ||||||||
| FaxNumber: | 5614345165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2011 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | R3392 | KY | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208G00000X | ME139818 | FL | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.