Basic Information
Provider Information | |||||||||
NPI: | 1902878861 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONGIOVANNI | ||||||||
FirstName: | JOSEPHINE | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6626 E. 75TH STREET | ||||||||
Address2: | SUITE 500 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462502890 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3176216333 | ||||||||
FaxNumber: | 3176216310 | ||||||||
Practice Location | |||||||||
Address1: | 9669 E 146TH ST | ||||||||
Address2: |   | ||||||||
City: | NOBLESVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 460605005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3176216300 | ||||||||
FaxNumber: | 3176216310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2006 | ||||||||
LastUpdateDate: | 09/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME71373 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 01071755A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 201111850 | 05 | IN |   | MEDICAID |