Provider Demographics
NPI:1225043896
Name:21ST CENTURY UROLOGY, S.C.
Entity Type:Organization
Organization Name:21ST CENTURY UROLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BONZANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-364-7000
Mailing Address - Street 1:14315 108TH AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5700
Mailing Address - Country:US
Mailing Address - Phone:708-364-7000
Mailing Address - Fax:708-364-8000
Practice Address - Street 1:14315 108TH AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5700
Practice Address - Country:US
Practice Address - Phone:708-364-7000
Practice Address - Fax:708-364-8000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097795Medicaid
IL5642652OtherAETNA PROVIDER NUMBER
IL036097795Medicaid
IL200878Medicare PIN