Provider Demographics
NPI:1255386900
Name:BONZHEIM, SCOTT C (PA)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:C
Last Name:BONZHEIM
Suffix:
Gender:M
Credentials:PA
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 685
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446
Mailing Address - Country:US
Mailing Address - Phone:866-898-7139
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:4272 W VIENNA RD
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-9454
Practice Address - Country:US
Practice Address - Phone:810-919-9415
Practice Address - Fax:810-686-1687
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISB002841363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISB002841OtherBCBS
S97040Medicare UPIN
MI0M92460029Medicare PIN
MISB002841OtherBCBS