MEDICARE: BONIFACE SURGICAL ASSOCIATES, LLC

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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1164106399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONIFACE SURGICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	8042 CAMDEN WAY
Second Line	:
City	:	CANFIELD
State	:	OH
Zip	:	44406-8164
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7600 SOUTHERN BLVD STE 2
Second Line	:
City	:	YOUNGSTOWN
State	:	OH
Zip	:	44512-6085
Country	:	US
Telephone Number	:	330-758-8183
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NICHOLAS BONIFACE
Credential	:	MD
Telephone Number	:	330-758-8183

Provider Enumeration Date	:	06/08/2023
Last Update Date	:	08/01/2023

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