Provider Demographics
NPI:1841269800
Name:WONGCHAOWART, BOONNUM (MD)
Entity type:Individual
Prefix:DR
First Name:BOONNUM
Middle Name:
Last Name:WONGCHAOWART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 BOYCE ROAD SUITE 2
Mailing Address - Street 2:SOUTH HILLS RECOVERY PROJECT
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15017
Mailing Address - Country:US
Mailing Address - Phone:724-260-5179
Mailing Address - Fax:724-942-3178
Practice Address - Street 1:850 BOYCE ROAD SUITE 2
Practice Address - Street 2:SOUTH HILLS RECOVERY PROJECT
Practice Address - City:BRIDGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15017
Practice Address - Country:US
Practice Address - Phone:724-260-5179
Practice Address - Fax:724-942-3178
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036134L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000552640Medicaid
PA000552640Medicaid
PA700208NBZMedicare ID - Type Unspecified