Healthcare Provider Details

I. General information

NPI: 1255386900
Provider Name (Legal Business Name): SCOTT C BONZHEIM PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4272 W VIENNA RD
CLIO MI
48420-9454
US

IV. Provider business mailing address

PO BOX 685
LAPEER MI
48446
US

V. Phone/Fax

Practice location:
  • Phone: 810-919-9415
  • Fax: 810-686-1687
Mailing address:
  • Phone: 866-898-7139
  • Fax: 616-975-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberSB002841
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: