Provider Demographics
NPI:1609883297
Name:MONACO, BRUCE R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:MONACO
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 426
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-0426
Mailing Address - Country:US
Mailing Address - Phone:620-432-5775
Mailing Address - Fax:620-431-1106
Practice Address - Street 1:1501 WEST 7TH ST.
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-2516
Practice Address - Country:US
Practice Address - Phone:620-432-5775
Practice Address - Fax:620-431-1106
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-051877207X00000X
KS04-39687207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
279500OtherMEDICARE GROUP
LA1813885Medicaid
P00058346OtherRAILROAD MEDICARE
IL036051877 2Medicaid
MS08673018Medicaid
L99688Medicare PIN
P00058346OtherRAILROAD MEDICARE
ILD13302Medicare UPIN
IL036051877 2Medicaid
LA4M557Medicare PIN