=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083983019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BONSALL MANFREDI & ASSOC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2011
-----------------------------------------------------
Last Update Date | 12/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 WOODLAWN STREET
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-221-0711
-----------------------------------------------------
Fax | 717-221-0435
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5A MELRON COURT
-----------------------------------------------------
City | CARLISLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-221-0711
-----------------------------------------------------
Fax | 717-221-0435
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD CERTIFIED CHILD/ADOLESCENT PS
-----------------------------------------------------
Name | DR. ERIC K. BONSALL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 717-221-0711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD036799E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------