MEDICARE: BONNIE P ELLENOFF DO

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	207Q00000X	Family Medicine Physician	051644	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306907001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE P ELLENOFF DO

Provider Business Mailing Address
First Line	:	3495 PIEDMONT RD NE
Second Line	:	NINE PIEDMONT CENTER
City	:	ATLANTA
State	:	GA
Zip	:	30305-1717
Country	:	US
Telephone Number	:	404-504-5678
Fax Number	:	404-370-0428

Provider Business Practice Location Address
First Line	:	3640 TRAMORE POINTE PKWY
Second Line	:	KAISER PERMANENTE WEST COBB MEDICAL CENTER
City	:	AUSTELL
State	:	GA
Zip	:	30106-6825
Country	:	US
Telephone Number	:	770-439-4700
Fax Number	:	404-370-0428

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	01/13/2022

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