1528036696 NPI number — BONNIE L. GRUNDEL PA-C

Table of content: BONNIE L. GRUNDEL PA-C (NPI 1528036696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528036696 NPI number — BONNIE L. GRUNDEL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRUNDEL
Provider First Name:
BONNIE
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528036696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 REDSTONE AVE W STE 490
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESTVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32536-6457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-689-8321
Provider Business Mailing Address Fax Number:
850-689-8322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
369 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32536-3541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-398-6963
Provider Business Practice Location Address Fax Number:
850-398-8277
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9101053 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y015K . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 17667 . This is a "HEALTH FIRST NETWORK" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P986780 . This is a "FREEDOM HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 291926500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P931666 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 123872 CRESTVIEW , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00900587 . This is a "RAILROAD MCR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 123873 SANTA ROSA , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102969300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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