1558327015 NPI number — DR. JUAN JOSE BONILLA MD

Table of content: MS. SHOLEH S BEHBAHANI PAC (NPI 1225076847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558327015 NPI number — DR. JUAN JOSE BONILLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONILLA
Provider First Name:
JUAN
Provider Middle Name:
JOSE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558327015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 WARRENVILLE RD
Provider Second Line Business Mailing Address:
STE 280
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60515-1721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-324-7900
Provider Business Mailing Address Fax Number:
630-271-1813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 N HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60506-1449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-801-5700
Provider Business Practice Location Address Fax Number:
630-801-5704
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  1049084 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: 036083958 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 36083958 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 526620 . This is a "COOK GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 202172 . This is a "URBANA/ROCKFORD/MOLINE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 344390 . This is a "DUPAGE GROUP" identifier . This identifiers is of the category "OTHER".




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