Healthcare Provider Details

I. General information

NPI: 1922082288
Provider Name (Legal Business Name): GERTRUDE KRISTINE BENNETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 JOHNSON FERRY RD NE SUITE 500
ATLANTA GA
30342-1619
US

IV. Provider business mailing address

975 JOHNSON FERRY RD NE SUITE 500
ATLANTA GA
30342-1619
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-1311
  • Fax: 404-705-2766
Mailing address:
  • Phone: 404-256-1311
  • Fax: 404-705-2766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number028140
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: