Healthcare Provider Details

I. General information

NPI: 1093751257
Provider Name (Legal Business Name): JULIUS P. BONELLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN STREET SUITE 300
PEORIA IL
61606
US

IV. Provider business mailing address

1001 MAIN STREET SUITE 300
PEORIA IL
61606
US

V. Phone/Fax

Practice location:
  • Phone: 309-495-0200
  • Fax: 309-676-6545
Mailing address:
  • Phone: 309-495-0200
  • Fax: 309-676-6545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036058876-1
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number036058876
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: