Healthcare Provider Details

I. General information

NPI: 1144205899
Provider Name (Legal Business Name): MATTHEW P BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 DR JOHN HAYNES DR
PELL CITY AL
35125-1438
US

IV. Provider business mailing address

2804 DR JOHN HAYNES DR
PELL CITY AL
35125-1438
US

V. Phone/Fax

Practice location:
  • Phone: 205-338-6655
  • Fax: 205-338-6658
Mailing address:
  • Phone: 205-338-6655
  • Fax: 205-338-6658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number00015383
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number15383
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number15383
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: