Healthcare Provider Details

I. General information

NPI: 1548480585
Provider Name (Legal Business Name): PATRICIA JOAN BONITATIBUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WOODLAWN RD
ALIQUIPPA PA
15001-5410
US

IV. Provider business mailing address

9 KENWOOD PL
WHEELING WV
26003-6042
US

V. Phone/Fax

Practice location:
  • Phone: 724-857-9640
  • Fax:
Mailing address:
  • Phone: 304-243-1027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD419757
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: