1275639692 NPI number — BRIAN NATHAN BENNETT D.P.M.

Table of content: BRIAN NATHAN BENNETT D.P.M. (NPI 1275639692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275639692 NPI number — BRIAN NATHAN BENNETT D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
BRIAN
Provider Middle Name:
NATHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1275639692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1416 WAINBROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30909-6289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-312-3668
Provider Business Mailing Address Fax Number:
706-312-3670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1416 WAINBROOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-6289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-312-3668
Provider Business Practice Location Address Fax Number:
706-312-3670
Provider Enumeration Date:
09/15/2006

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: 213ES0103X , with the licence number:  POD000842 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2700070 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 4292280003 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GPD842 . This is a "SOUTH CAROLINA MEDICAID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 2592457 . This is a "AETNA HMO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 7052274 . This is a "BCBS OF GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00812985B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7104253 . This is a "AETNA PPO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000812985C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480032159 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com