Basic Information
| Provider Information | |||||||||
| NPI: | 1255386900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONZHEIM | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 685 | ||||||||
| Address2: | |||||||||
| City: | LAPEER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987139 | ||||||||
| FaxNumber: | 6169759827 | ||||||||
| Practice Location | |||||||||
| Address1: | 4272 W VIENNA RD | ||||||||
| Address2: | |||||||||
| City: | CLIO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484209454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109199415 | ||||||||
| FaxNumber: | 8106861687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | SB002841 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | SB002841 | 01 | MI | BCBS | OTHER |