=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417945577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOB B. PONTILLAS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2005
-----------------------------------------------------
Last Update Date | 02/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 N MAIN ST SUITE D
-----------------------------------------------------
City | ANNA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62906-1668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-833-2872
-----------------------------------------------------
Fax | 618-833-2414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 MERIDIAN BLVD ATTN: DEBBIE BREWER
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37067-6325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-465-7000
-----------------------------------------------------
Fax | 615-465-2884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 33163
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------