Basic Information
| Provider Information | |||||||||
| NPI: | 1316904121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | BONNI | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219220190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103984679 | ||||||||
| FaxNumber: | 4106203686 | ||||||||
| Practice Location | |||||||||
| Address1: | 361 FAIR HILL DR | ||||||||
| Address2: | |||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219212512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106207260 | ||||||||
| FaxNumber: | 4106207262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | H0062851 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C2-0007295 | DE | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 408570100 | 05 | MD | MEDICAID | P00266351 | 01 | MEDICARE RAILROAD | OTHER |