Provider Demographics
NPI:1275632630
Name:BONAVENTURE PAIN MANAGEMENT
Entity Type:Organization
Organization Name:BONAVENTURE PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD OF GROUP
Authorized Official - Prefix:
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-394-4445
Mailing Address - Street 1:804 SCOTT NIXON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 SCOTT NIXON MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-2464
Practice Address - Country:US
Practice Address - Phone:800-394-4445
Practice Address - Fax:706-434-8871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044246207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID