1730159732 NPI number — MRS. BRIDGET STINE BONGAARD MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730159732 NPI number — MRS. BRIDGET STINE BONGAARD MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BONGAARD

Provider First Name:

BRIDGET

Provider Middle Name:

STINE

Provider Name Prefix Text:

MRS.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1730159732

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

08/25/2014

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 602344

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CHARLOTTE

Provider Business Mailing Address State Name:

NC

Provider Business Mailing Address Postal Code:

28260-2344

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

704-403-7050

Provider Business Mailing Address Fax Number:

704-403-7059

Provider First Line Business Practice Location Address:

707 MEMORIAL BLVD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CONCORD

Provider Business Practice Location Address State Name:

NC

Provider Business Practice Location Address Postal Code:

28025-2975

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

704-403-7050

Provider Business Practice Location Address Fax Number:

704-403-7059

Provider Enumeration Date:

01/24/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  28133 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 175F00000X , with the licence number: 28133 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 1730159732 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 8102223 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 177664 . This is a "WELLPATH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 11176 . This is a "PARTNERS MEDICARE CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 1205616 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 1639733 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 16783 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 4102703 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 8916783 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 203598K . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: A9136 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".