1184658056 NPI number — IVAN R BENNETT PA

Table of content: HAILEY OLSON PHARMD (NPI 1275971939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184658056 NPI number — IVAN R BENNETT PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
IVAN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184658056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636256 CENTRAL CREDENTIALING
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-6256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-585-5506
Provider Business Mailing Address Fax Number:
513-585-5511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7798 DISCOVERY DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST CHESTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45069-6542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-939-2263
Provider Business Practice Location Address Fax Number:
513-874-4579
Provider Enumeration Date:
07/10/2006

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: 363AS0400X , with the licence number:  50-002463 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 50002463 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100001230 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: BEPA27101 . This is a "MEDICARE CGS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".