Provider Demographics
NPI:1083235188
Name:BONZER MEDICAL, LLC
Entity type:Organization
Organization Name:BONZER MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANANGER
Authorized Official - Phone:765-653-8453
Mailing Address - Street 1:4423 S COUNTY ROAD 125 E
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-9237
Mailing Address - Country:US
Mailing Address - Phone:765-653-8453
Mailing Address - Fax:765-653-8493
Practice Address - Street 1:4423 S COUNTY ROAD 125 E
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-9237
Practice Address - Country:US
Practice Address - Phone:765-653-8453
Practice Address - Fax:765-653-8493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200521550Medicaid
IN02002904AMedicaid