Provider Demographics
NPI:1245316827
Name:GERECKE, BONNIE J (MD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:J
Last Name:GERECKE
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 1:301 SAINT PAUL PL
Mailing Address - Street 2:SUTIE 402
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:410-649-3485
Mailing Address - Fax:410-659-2817
Practice Address - Street 1:301 SAINT PAUL PL
Practice Address - Street 2:SUTIE 402
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-649-3485
Practice Address - Fax:410-659-2817
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO64758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00729836OtherR/R MEDICARE PIN
MDS576Medicare PIN
MD128325Y4HMedicare PIN