Basic Information
| Provider Information | |||||||||
| NPI: | 1447619101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULAS-MERCURI | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BULAS | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | BOX 8000 DEPT 314 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162130772 | ||||||||
| FaxNumber: | 7163245004 | ||||||||
| Practice Location | |||||||||
| Address1: | 5190 TRANSIT RD | ||||||||
| Address2: | |||||||||
| City: | DEPEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140434324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166510100 | ||||||||
| FaxNumber: | 7166510151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2016 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 040659 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 05710292 | 05 | NY | MEDICAID |