Healthcare Provider Details

I. General information

NPI: 1104854553
Provider Name (Legal Business Name): BENNY LEE SHORT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ROSS BLVD
DODGE CITY KS
67801-7221
US

IV. Provider business mailing address

200 W ROSS BLVD
DODGE CITY KS
67801-7221
US

V. Phone/Fax

Practice location:
  • Phone: 620-371-7300
  • Fax: 620-371-7304
Mailing address:
  • Phone: 620-371-7300
  • Fax: 620-371-7304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-28386
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04-28386
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: