1013988708 NPI number — DR. STEVEN WESLEY BENNETT

Table of content: DR. STEVEN WESLEY BENNETT (NPI 1013988708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013988708 NPI number — DR. STEVEN WESLEY BENNETT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
STEVEN
Provider Middle Name:
WESLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENNETT
Provider Other First Name:
STEVEN
Provider Other Middle Name:
W.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.P.M.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1013988708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 ROYAL FERN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR MILL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21244-1164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-447-1661
Provider Business Mailing Address Fax Number:
410-466-2154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2414 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21217-1722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-447-1661
Provider Business Practice Location Address Fax Number:
410-466-2154
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  01235 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 700501600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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