Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 036094353 | IL |
NPI | 1013925387 |
---|---|
Provider Name | Dr. Goldwyn Bonner Foggie |
First Address | Evergreen Park, IL 60805-2814 |
Second Address | Harvey, IL 60426-4171 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2006 |
Last Update Date | 03/11/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036094353 | (05) | IL |
71346 | (02) | IL |