Provider Demographics
NPI:1497794200
Name:SHANIS, BONNIE (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:SHANIS
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 1:1 CONRAD DR
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-4008
Mailing Address - Country:US
Mailing Address - Phone:215-542-5899
Mailing Address - Fax:
Practice Address - Street 1:1 CONRAD DR
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-4008
Practice Address - Country:US
Practice Address - Phone:215-542-5899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018891E207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
B38863Medicare UPIN
138211Medicare ID - Type Unspecified