Provider Demographics
NPI:1699785881
Name:BONFIGLIO, RANDALL C (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:C
Last Name:BONFIGLIO
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:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:MURRYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15668-0248
Mailing Address - Country:US
Mailing Address - Phone:412-977-0980
Mailing Address - Fax:724-387-1033
Practice Address - Street 1:5620 WILLIAM PENN HWY
Practice Address - Street 2:
Practice Address - City:MURRYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15632-9035
Practice Address - Country:US
Practice Address - Phone:412-780-0741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091328208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019122100001Medicaid
MIH49856Medicare UPIN
MIP53000001Medicare PIN