Provider Demographics
NPI:1346256047
Name:BONAMINIO, EMO
Entity Type:Individual
Prefix:
First Name:EMO
Middle Name:
Last Name:BONAMINIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5917
Mailing Address - Country:US
Mailing Address - Phone:847-458-4600
Mailing Address - Fax:847-458-4602
Practice Address - Street 1:1441 MERCHANT DR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-1289
Practice Address - Country:US
Practice Address - Phone:847-458-4600
Practice Address - Fax:847-458-4602
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004710213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004710Medicaid
ILU56639Medicare UPIN