Basic Information
| Provider Information | |||||||||
| NPI: | 1386630796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONEY | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | WEINBERG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEINBERG | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | JOHANNA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6605 ABERCORN ST | ||||||||
| Address2: | SUITE108 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314055815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123557214 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6605 ABERCORN ST | ||||||||
| Address2: | SUITE108 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314055815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123557214 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036480 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 036480 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000664001D | 05 | GA | MEDICAID |