Provider Demographics
NPI:1285694877
Name:BONGIORNO, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BONGIORNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-9900
Mailing Address - Fax:215-707-3831
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-9900
Practice Address - Fax:215-707-3831
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025380E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA597586OtherMEDICARE TPI GROUP
PA001041536Medicaid
PA1007278000114OtherMEDICAID TPI GROUP
PACD4829OtherRAILROAD MEDICARE TPI GROUP
NJ5173701Medicaid
PA001041536Medicaid
0000179093Medicare ID - Type Unspecified
B40752Medicare UPIN