Basic Information
| Provider Information | |||||||||
| NPI: | 1285687996 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BONUTTI ORTHOPEDIC SERVICES LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SARAH BUSH LINCOLN BONUTTI CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 W EVERGREEN AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624011619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173423400 | ||||||||
| FaxNumber: | 2173426416 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 W EVERGREEN AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173423400 | ||||||||
| FaxNumber: | 2173426416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | PLUARD | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO & VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2172582102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRACTICE ACQUISITION INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | 060005120 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 207XS0106X | 060005120 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0117X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 2083S0010X | 060005120 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Sports Medicine | 207X00000X | 060005120 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 166708 | 01 | IL | HEALTHLINK | OTHER | 2500074 | 01 | IL | BLUECROSS BLUE SHIELD | OTHER |