Healthcare Provider Details

I. General information

NPI: 1316018260
Provider Name (Legal Business Name): MARIAN BENNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BROADWAY
BANGOR ME
04401-3979
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-1550
  • Fax: 207-907-3052
Mailing address:
  • Phone: 207-777-8560
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberMD16834
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD16834
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: