Provider Demographics
NPI:1811372345
Name:BONHOEFFER RHEUMATOLOGY INSTITUTE, LLC
Entity Type:Organization
Organization Name:BONHOEFFER RHEUMATOLOGY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:W
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:480-494-2770
Mailing Address - Street 1:2451 E BASELINE RD
Mailing Address - Street 2:SUITE 425
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2471
Mailing Address - Country:US
Mailing Address - Phone:480-494-2770
Mailing Address - Fax:480-494-2771
Practice Address - Street 1:2451 E BASELINE RD
Practice Address - Street 2:SUITE 425
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2471
Practice Address - Country:US
Practice Address - Phone:480-494-2770
Practice Address - Fax:480-494-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12739741261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2015015625OtherANCC
AZ041844Medicaid
AZ12739741OtherCAQH
AZ12739741OtherCAQH
AZ041844Medicaid