Basic Information
| Provider Information | |||||||||
| NPI: | 1629021571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONUTTI | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178682812 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1303 W EVERGREEN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624011638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173423400 | ||||||||
| FaxNumber: | 2173423477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036078905 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 178970 | 01 | IL | HEALTHLINK | OTHER | 036078905 | 05 | IL | MEDICAID |