Provider Demographics
NPI:1881052454
Name:WAYNE R. BONLIE, M.D., P.A
Entity type:Organization
Organization Name:WAYNE R. BONLIE, M.D., P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BONLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-560-7404
Mailing Address - Street 1:30 E PADONIA RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2345
Mailing Address - Country:US
Mailing Address - Phone:410-560-7404
Mailing Address - Fax:443-588-1725
Practice Address - Street 1:30 E PADONIA RD
Practice Address - Street 2:SUITE 305
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2345
Practice Address - Country:US
Practice Address - Phone:410-560-7404
Practice Address - Fax:443-588-1725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062606261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care