Healthcare Provider Details

I. General information

NPI: 1477839702
Provider Name (Legal Business Name): CHARLES W BENNETT MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11845 HG TRUEMAN RD
LUSBY MD
20657-2855
US

IV. Provider business mailing address

11845 HG TRUEMAN RD
LUSBY MD
20657-2855
US

V. Phone/Fax

Practice location:
  • Phone: 410-326-6344
  • Fax: 410-326-0079
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD43306
License Number StateMD

VIII. Authorized Official

Name: CHARLES W BENNETT
Title or Position: OWNER
Credential:
Phone: 410-326-6344