Provider Demographics
NPI:1841289527
Name:BONAMINIO, PHYLLIS N (MD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:N
Last Name:BONAMINIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 W COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1001
Mailing Address - Country:US
Mailing Address - Phone:708-361-0600
Mailing Address - Fax:708-923-2329
Practice Address - Street 1:5540 W 111TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5574
Practice Address - Country:US
Practice Address - Phone:708-423-8440
Practice Address - Fax:708-658-2962
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104900207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H87670Medicare UPIN
K20312Medicare ID - Type Unspecified