Basic Information
| Provider Information | |||||||||
| NPI: | 1306907001 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLENOFF | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045045678 | ||||||||
| FaxNumber: | 4043700428 | ||||||||
| Practice Location | |||||||||
| Address1: | 3640 TRAMORE POINTE PKWY | ||||||||
| Address2: | KAISER PERMANENTE WEST COBB MEDICAL CENTER | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704394700 | ||||||||
| FaxNumber: | 4043700428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 051644 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0009593950 | 05 | GA | MEDICAID |