Healthcare Provider Details

I. General information

NPI: 1679597470
Provider Name (Legal Business Name): JORDAN BRADLEY BONOMO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 01/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 ALBERT SABIN WAY ML 0769
CINCINNATI OH
45267-0769
US

IV. Provider business mailing address

2830 VICTORY PKWY CENTRAL CREDENTIALING DEPARTMENT ML0806
CINCINNATI OH
45206-1785
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-5281
  • Fax: 513-558-5791
Mailing address:
  • Phone: 513-245-3667
  • Fax: 513-475-7259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.087498
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: