Provider Demographics
NPI:1285620781
Name:BULAWA, BETH ANN (MD)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:BULAWA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:1404 TUSCULUM BLVD STE 2100
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4329
Practice Address - Country:US
Practice Address - Phone:423-783-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191942208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1532375Medicaid
NY01452991Medicaid
TN1532375OtherBLUECARE
TN4356397OtherBCBST
TNP01225987OtherRAILROAD MEDICARE
TN103I024861Medicare PIN
F62801Medicare UPIN
NYJ400002886Medicare PIN