Basic Information
| Provider Information | |||||||||
| NPI: | 1861492464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FINES | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PANKOV | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 7366 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563027366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202575595 | ||||||||
| FaxNumber: | 3202575596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1990 CONNECTICUT AVE S | ||||||||
| Address2: | |||||||||
| City: | SARTELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563772554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202575595 | ||||||||
| FaxNumber: | 3202575596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 45537 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1837757 | 01 | MN | ARAZ/ AMERICA'S PPO | OTHER | 16-02511 | 01 | MN | MEDICA | OTHER | 171476C561 | 01 | MN | UCARE OF MINNESOTA | OTHER | 411772562 | 01 | MN | TRICARE | OTHER | 227M2FI | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | HP38538 | 01 | MN | HEALTH PARTNERS | OTHER | 310439700 | 05 | MN | MEDICAID | 411772562 | 01 | MN | GREATWEST HEALTHCARE | OTHER | 965251034363 | 01 | MN | PREFERRED ONE | OTHER | P00025241 | 01 | MN | RAILROAD MEDICARE | OTHER |