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General NPI Number Information
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NPI Number | 1962866566
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Entity Type | Organization
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Legal Business Name | PREMIER PEDIATRIC CARDIOLOGY LLC
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Dates
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Enumeration Date | 04/09/2016
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Last Update Date | 10/20/2016
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Provider Practice Location Address
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Address Line | 750 ROUTE 73 S
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City | MARLTON
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State | NJ
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Zip | 08053-4141
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Country | US
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Telephone | 856-872-2868
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Fax | 856-872-2876
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Provider Business Mailing Address
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Address Line | 333 E LANCASTER AVE #334
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City | WYNNEWOOD
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State | PA
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Zip | 19096-1929
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Country | US
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Telephone | 856-872-2868
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. WILLIAM BONNEY
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Credential | M.D.
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Telephone | 856-872-2868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number | MD436538
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number | 25MA08663900
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License Number State | NJ
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