1851390769 NPI number — ANNMARIE ELIZABETH BONETTI D.O.

Table of content: ANNMARIE ELIZABETH BONETTI D.O. (NPI 1851390769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851390769 NPI number — ANNMARIE ELIZABETH BONETTI D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONETTI
Provider First Name:
ANNMARIE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851390769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9471 MARKET ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
NORTH LIMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44452-8702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-729-2388
Provider Business Mailing Address Fax Number:
330-629-6468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 ROYAL BIRKDALE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COLUMBIANA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-482-9350
Provider Business Practice Location Address Fax Number:
330-482-2336
Provider Enumeration Date:
07/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34-00-8108 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2450628 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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