Provider Demographics
NPI:1740261726
Name:CRICKMAN, BONNIE L (MD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:CRICKMAN
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:501 CARNES CROSSING BLVD STE B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486
Practice Address - Country:US
Practice Address - Phone:843-212-8080
Practice Address - Fax:843-203-2299
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC003OtherBCBS
SC032OtherTRICARE
SC118036Medicaid
SC6201460OtherCIGNA
SCB924498552OtherMEDICARE PTAN
SC20079153OtherSELECT HEALTH
SC034OtherTRICARE
SC5208053OtherAETNA
SC000000248853OtherUNISON
SC063OtherBLUECHOICE
SC061OtherBLUECHOICE
SC211988OtherMEDCOST
NC5910323Medicaid
SC063OtherBLUECHOICE
SC034OtherTRICARE