Basic Information
| Provider Information | |||||||||
| NPI: | 1134206188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONADIO | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 AMSTERDAM AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100251716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3477632409 | ||||||||
| FaxNumber: | 6518552310 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 AMSTERDAM AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100251716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125234000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/29/2021 | ||||||||
| NPIReactivationDate: | 08/25/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 36476 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PP0204X | 36476 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 208000000X | 36476 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 36476 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 535762400 | 05 | MN | MEDICAID |