Healthcare Provider Details

I. General information

NPI: 1538687272
Provider Name (Legal Business Name): MICHAEL G BONEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N KEENE ST
COLUMBIA MO
65201-6626
US

IV. Provider business mailing address

7701 E EAST CT
COLUMBIA MO
65201-7001
US

V. Phone/Fax

Practice location:
  • Phone: 573-771-9400
  • Fax:
Mailing address:
  • Phone: 816-547-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP11730
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2010016740
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: