Healthcare Provider Details

I. General information

NPI: 1831107499
Provider Name (Legal Business Name): BENTON MEDICAL AND SURGICAL ASSOCIATES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 OLD SYMSONIA ROAD SUITE A
BENTON KY
42025-5042
US

IV. Provider business mailing address

619 OLD SYMSONIA ROAD SUITE A
BENTON KY
42025-5042
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-7400
  • Fax: 270-527-2211
Mailing address:
  • Phone: 270-527-7400
  • Fax: 270-527-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32012
License Number StateKY

VIII. Authorized Official

Name: ROBERT BEALE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 270-527-7400