MEDICARE: DR. JORDAN BRADLEY BONOMO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	35.087498	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679597470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN BRADLEY BONOMO MD

Provider Business Mailing Address
First Line	:	2830 VICTORY PKWY
Second Line	:	CENTRAL CREDENTIALING DEPARTMENT ML0806
City	:	CINCINNATI
State	:	OH
Zip	:	45206-1785
Country	:	US
Telephone Number	:	513-245-3667
Fax Number	:	513-475-7259

Provider Business Practice Location Address
First Line	:	231 ALBERT SABIN WAY
Second Line	:	ML 0769
City	:	CINCINNATI
State	:	OH
Zip	:	45267-0769
Country	:	US
Telephone Number	:	513-558-5281
Fax Number	:	513-558-5791

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	01/29/2010

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