=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609338748
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WYNDHAM ALEXANDER BONETT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2019
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 N MEADOWS DR STE C
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37303-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-648-8480
-----------------------------------------------------
Fax | 423-648-8481
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 197517
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37219-7517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-648-8480
-----------------------------------------------------
Fax | 423-648-8481
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | MD.41341
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 71520
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------