Healthcare Provider Details

I. General information

NPI: 1942865548
Provider Name (Legal Business Name): MILES KIERNAN BONNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 10/09/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MULLICA HILL RD
MULLICA HILL NJ
08062-4413
US

IV. Provider business mailing address

1 FEDERAL ST STE 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-508-1000
  • Fax:
Mailing address:
  • Phone: 848-288-6935
  • Fax: 732-790-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MB12373400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: