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1134141401

NPI Code Detail

MEDICARE: DR. BENNY CARROLL MULLINS

MEDICARE: DR. BENNY CARROLL MULLINS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0101025318	VA
2	207P00000X	Emergency Medicine Physician	0101025318	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	EIN CO2259	OTHER	VA	EIN

General Provider Information

NPI Number	:	1134141401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENNY CARROLL MULLINS

Provider Business Mailing Address
First Line	:	15698 MONTICELLO DR
Second Line	:
City	:	BRISTOL
State	:	VA
Zip	:	24202-4110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	340 BAGLEY CIR
Second Line	:
City	:	MARION
State	:	VA
Zip	:	24354-3126
Country	:	US
Telephone Number	:	276-783-1201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	03/25/2011

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1598735417 — DR. JONATHAN GENTRY CRISP MD
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Directions to “ DR. BENNY CARROLL MULLINS ” Practice Location

Language	Start Address	Practice Location

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