Provider Demographics
NPI:1861492944
Name:BONNELL, BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:BONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 HUNTINGDON PIKE
Mailing Address - Street 2:MEDICAL STAFF OFFICE 1ST FLR
Mailing Address - City:MEADOWBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19046-8001
Mailing Address - Country:US
Mailing Address - Phone:215-938-3450
Mailing Address - Fax:215-938-3829
Practice Address - Street 1:8580 VERREE RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-1370
Practice Address - Country:US
Practice Address - Phone:215-214-3815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD469659207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3170730Medicaid
MAG53213Medicare UPIN
MAA31557Medicare ID - Type Unspecified