Basic Information
| Provider Information | |||||||||
| NPI: | 1558785816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULZOMI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1554 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117900988 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | STONY BROOK UNIV HOSP DEPT OF E M | ||||||||
| Address2: | HSC, LEVEL 4, ROOM 080 | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117948350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314444000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2014 | ||||||||
| LastUpdateDate: | 11/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 017295-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 04295341 | 05 | NY | MEDICAID | A400131985 | 01 | NY | MEDICARE PROVIDER NUMBER | OTHER |