MEDICARE: AMANDA K BENNETT MD

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	0101238081	VA
2	207Q00000X	Family Medicine Physician	21674	WV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00318137	OTHER	WV	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578533345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA K BENNETT MD

Provider Business Mailing Address
First Line	:	PO BOX 1680
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25707-1680
Country	:	US
Telephone Number	:	304-697-1396
Fax Number	:	304-697-2086

Provider Business Practice Location Address
First Line	:	2585 3RD AVENUE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25703
Country	:	US
Telephone Number	:	304-781-5138
Fax Number	:

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

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	07/29/2008

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