Healthcare Provider Details

I. General information

NPI: 1285687996
Provider Name (Legal Business Name): BONUTTI ORTHOPEDIC SERVICES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 W EVERGREEN AVE SUITE 101
EFFINGHAM IL
62401
US

IV. Provider business mailing address

1303 W EVERGREEN AVE STE 101
EFFINGHAM IL
62401-1619
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-3400
  • Fax: 217-342-6416
Mailing address:
  • Phone: 217-342-3400
  • Fax: 217-342-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number060005120
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number060005120
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number060005120
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number060005120
License Number StateIL

VIII. Authorized Official

Name: DENNIS PLUARD
Title or Position: CFO & VP OF OPERATIONS
Credential:
Phone: 217-258-2102