MEDICARE: DR. MARIE ROSE BONABON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	23996	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093775397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIE ROSE BONABON M.D.

Provider Business Mailing Address
First Line	:	800 PELHAM RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-3300
Country	:	US
Telephone Number	:	864-234-5800
Fax Number	:	864-284-0844

Provider Business Practice Location Address
First Line	:	309 W BUTLER RD
Second Line	:
City	:	MAULDIN
State	:	SC
Zip	:	29662-2531
Country	:	US
Telephone Number	:	864-297-1575
Fax Number	:	864-284-0844

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	07/08/2007

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