Provider Demographics
NPI:1811949191
Name:BONGIOVANNI, ANDREW G (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:G
Last Name:BONGIOVANNI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1991 SPROUL RD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3512
Mailing Address - Country:US
Mailing Address - Phone:484-427-8999
Mailing Address - Fax:484-421-3001
Practice Address - Street 1:1991 SPROUL RD
Practice Address - Street 2:SUITE 450
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3512
Practice Address - Country:US
Practice Address - Phone:484-427-8999
Practice Address - Fax:484-421-3001
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS003771L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1433150OtherCIGNA
PA0031332000OtherKEYSTONE HEALTH PLAN EAST
PA4110849OtherAETNA PPO
PA438313OtherBLUE SHIELD
PA0009604000003Medicaid
PA438313SA3Medicare PIN
PAP00278570Medicare PIN
PA19346OtherAETNA HMO
PA30034885OtherKMHP