Provider Demographics
NPI:1851440028
Name:BONNER SPORTS AND PHYSICAL MEDICINE, INC..
Entity Type:Organization
Organization Name:BONNER SPORTS AND PHYSICAL MEDICINE, INC..
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-547-6611
Mailing Address - Street 1:333 N OXFORD VALLEY RD
Mailing Address - Street 2:#102
Mailing Address - City:FAIRLESS HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19030-2624
Mailing Address - Country:US
Mailing Address - Phone:215-554-7661
Mailing Address - Fax:215-547-1054
Practice Address - Street 1:333 N OXFORD VALLEY RD
Practice Address - Street 2:#102
Practice Address - City:FAIRLESS HILLS
Practice Address - State:PA
Practice Address - Zip Code:19030-2624
Practice Address - Country:US
Practice Address - Phone:215-547-6611
Practice Address - Fax:215-547-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA071950000OtherIBX
PA1539034Medicaid
PA2426694000OtherIBX
PA5461117OtherAETNA
PA5461117OtherAETNA