Provider Demographics
NPI:1740487545
Name:BONEBRAKE, MICHAEL L (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:BONEBRAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2 SAINT ANTHONYS WAY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4569
Mailing Address - Country:US
Mailing Address - Phone:618-465-9024
Mailing Address - Fax:618-462-6828
Practice Address - Street 1:2 SAINT ANTHONYS WAY
Practice Address - Street 2:SUITE 305
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4569
Practice Address - Country:US
Practice Address - Phone:618-465-9024
Practice Address - Fax:618-462-6828
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAR8024208600000X
MO20120159112086S0102X
IL036133685208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400101280Medicare UPIN