MEDICARE: ANGELA M BENNETT MEDICAL CORPORATION

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

General Provider Information

NPI Number	:	1831358605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELA M BENNETT MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 693
Second Line	:
City	:	GATES MILLS
State	:	OH
Zip	:	44040-0693
Country	:	US
Telephone Number	:	216-561-8000
Fax Number	:	216-561-8005

Provider Business Practice Location Address
First Line	:	20050 HARVARD AVENUE
Second Line	:	SUITE 107
City	:	WARRENSVILLE HEIGHTS
State	:	OH
Zip	:	44122-6800
Country	:	US
Telephone Number	:	216-561-8000
Fax Number	:	216-561-8005

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANGELA MILLER BENNETT
Credential	:	MD
Telephone Number	:	216-561-8000

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	06/23/2008

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