1548224686 NPI number — DR. WILLIAM BONZELET MD

Table of content: DR. WILLIAM BONZELET MD (NPI 1548224686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548224686 NPI number — DR. WILLIAM BONZELET MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONZELET
Provider First Name:
WILLIAM
Provider Middle Name:
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:
1548224686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6810 STATE RT 162 BOX 215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62062-8501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-391-6405
Provider Business Mailing Address Fax Number:
618-288-4088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SEVEN 157 CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDWARDSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-659-2371
Provider Business Practice Location Address Fax Number:
618-659-2375
Provider Enumeration Date:
04/14/2006

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: 207R00000X , with the licence number:  036091754 , 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: 112688 . This is a "BCBS MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: B51654 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 68241 . This is a "PRUCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036091754 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0409003 . This is a "MEDICARE COMPLETE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 112688 . This is a "BLUECHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 277675 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0401769 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 06022637 . This is a "BCBS IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 112688 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33167 . This is a "HEALTHPARTNERS GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33031 . This is a "ADVANTRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33031 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4652964 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 371385704 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6022637 . This is a "BLUECARD" identifier . This identifiers is of the category "OTHER".




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