Provider Demographics
NPI:1134129091
Name:MONTELLA, BRUCE J (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:J
Last Name:MONTELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 807
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60009-0807
Mailing Address - Country:US
Mailing Address - Phone:847-437-9889
Mailing Address - Fax:847-437-4149
Practice Address - Street 1:901 BIESTERFIELD RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3392
Practice Address - Country:US
Practice Address - Phone:847-437-9889
Practice Address - Fax:847-437-4149
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31603457OtherBLUE CROSS BLUE SHIELD #
IL31603457OtherBLUE CROSS BLUE SHIELD #
ILK19415Medicare PIN
IL212020Medicare PIN
IL0526070004Medicare NSC
ILG42366Medicare UPIN