Basic Information
| Provider Information | |||||||||
| NPI: | 1003878794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONYAK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342005252 | ||||||||
| FaxNumber: | 4342005252 | ||||||||
| Practice Location | |||||||||
| Address1: | 2410 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342005252 | ||||||||
| FaxNumber: | 4342005252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 04/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 0101048188 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 20934 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000875693 | 01 | WV BLUE SHIELD - GROUP # | OTHER | 43935 | 01 | SENTARA PROFESSIONAL | OTHER | C00085 | 01 | VA MEDICARE B - GROUP # | OTHER | 000486018 | 01 | WV BLUE SHIELD | OTHER | 211032 | 01 | ANTHEM PROFESSIONAL | OTHER | 9371521 | 01 | WV | WV MEDICARE B - GROUP # | OTHER | 08251100000 | 01 | QUALCHOICE | OTHER | 9371521 | 01 | WV | WV MEDICARE GRP NEW | OTHER | P00656327 | 01 | RAILROAD MEDICARE | OTHER | 2119629 | 01 | MAMSI PROFESSIONAL | OTHER | 3810003817 | 01 | WV | WV MEDICAID GROUP | OTHER | 006051120 | 05 | VA | MEDICAID | 0086502000 | 05 | WV | MEDICAID | 550941600 | 01 | MD | MD MEDICAID GRP IN VA | OTHER | 9332051 | 01 | WV | WV MEDICARE B - GROUP # | OTHER | 9332051 | 01 | WV | WV MEDICARE GRP OLD | OTHER |