Provider Demographics
NPI:1962866566
Name:PREMIER PEDIATRIC CARDIOLOGY LLC
Entity Type:Organization
Organization Name:PREMIER PEDIATRIC CARDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-872-2868
Mailing Address - Street 1:333 E LANCASTER AVE
Mailing Address - Street 2:#334
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-1929
Mailing Address - Country:US
Mailing Address - Phone:856-872-2868
Mailing Address - Fax:
Practice Address - Street 1:750 ROUTE 73 S
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4141
Practice Address - Country:US
Practice Address - Phone:856-872-2868
Practice Address - Fax:856-872-2876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-09
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA086639002080P0202X
PAMD4365382080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty