Provider Demographics
NPI:1699771998
Name:BONNELL, BRUCE W (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:W
Last Name:BONNELL
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:MC 031
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-6488
Practice Address - Fax:616-391-6428
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI035272208600000X
MI43010352722086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI791023924OtherRAILROAD MEDICARE
MIM36590051Medicare PIN
MI1730283OtherIBA HEALTH PLANS
MIB45440Medicare UPIN
1558407189OtherGROUP NPI
MI382031033105OtherCOMMUNITY CHOICE MICHIGAN
MI0D17641002OtherMEDICARE PLUS BLUE
1922090554OtherCORP NPI
MI4013025OtherAETNA
MI4166312001OtherCIGNA
MI020D176410OtherBLUECARE NETWORK GROUP
MI0985694OtherHEALTHPLUS OF MI HMO
MI1306130Medicaid
MI504606OtherPREFERRED CHOICES
MI0D17641002Medicare ID - Type UnspecifiedMEDICARE PPI