Healthcare Provider Details

I. General information

NPI: 1770511925
Provider Name (Legal Business Name): BONNIE JEAN NOWACZYK M D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 WEISS ST
SAGINAW MI
48602-5251
US

IV. Provider business mailing address

8980 WEBSTER RD
FREELAND MI
48623-9019
US

V. Phone/Fax

Practice location:
  • Phone: 989-497-2500
  • Fax:
Mailing address:
  • Phone: 989-695-2635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number4301047035
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: