Basic Information
| Provider Information | |||||||||
| NPI: | 1083235188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONZER MEDICAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4423 S COUNTY ROAD 125 E | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461359237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656538453 | ||||||||
| FaxNumber: | 7656538493 | ||||||||
| Practice Location | |||||||||
| Address1: | 4423 S COUNTY ROAD 125 E | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461359237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656538453 | ||||||||
| FaxNumber: | 7656538493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2020 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | CRAMER | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
| AuthorizedOfficialMiddleName: | LOUISE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7656538453 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OFFICE MANANGER | ||||||||
| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 200521550 | 05 | IN | MEDICAID | 02002904A | 05 | IN | MEDICAID |