Basic Information
Provider Information | |||||||||
NPI: | 1730159732 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONGAARD | ||||||||
FirstName: | BRIDGET | ||||||||
MiddleName: | STINE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 602344 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282602344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044037050 | ||||||||
FaxNumber: | 7044037059 | ||||||||
Practice Location | |||||||||
Address1: | 707 MEMORIAL BLVD | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280252975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044037050 | ||||||||
FaxNumber: | 7044037059 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2006 | ||||||||
LastUpdateDate: | 08/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 28133 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 175F00000X | 28133 | NC | N |   | Other Service Providers | Naturopath |   |
ID Information
ID | Type | State | Issuer | Description | 1730159732 | 05 | NC |   | MEDICAID | 8102223 | 01 | NC | MAMSI | OTHER | 177664 | 01 | NC | WELLPATH | OTHER | 11176 | 01 | NC | PARTNERS MEDICARE CHOICE | OTHER | 1205616 | 01 | NC | UNITED HEALTHCARE | OTHER | 1639733 | 01 | NC | CIGNA HEALTHCARE | OTHER | 16783 | 01 | NC | BCBSNC | OTHER | 4102703 | 01 | NC | AETNA | OTHER | 8916783 | 05 | NC |   | MEDICAID | 203598K | 01 | NC | MEDICARE PTAN | OTHER | A9136 | 01 | NC | MEDCOST | OTHER |