Healthcare Provider Details

I. General information

NPI: 1730804931
Provider Name (Legal Business Name): ANNELISE BONVILLAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 06/25/2023
Certification Date: 06/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH STREET, BI-2183 AUGUSTA, GA 30912
AUGUSTA GA
30912
US

IV. Provider business mailing address

1120 15TH STREET, BI-2183 AUGUSTA, GA 30912
AUGUSTA GA
30912
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0180
  • Fax:
Mailing address:
  • Phone: 706-721-0180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number15206
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: