Healthcare Provider Details

I. General information

NPI: 1194346536
Provider Name (Legal Business Name): BENJAMIN S SUTTON RRA, RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N BROAD ST NE
ROME GA
30161-5201
US

IV. Provider business mailing address

901 N BROAD ST NE
ROME GA
30161-5201
US

V. Phone/Fax

Practice location:
  • Phone: 706-291-2661
  • Fax:
Mailing address:
  • Phone: 706-291-2661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number20RRANC1274
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: