Healthcare Provider Details

I. General information

NPI: 1447543772
Provider Name (Legal Business Name): LUKE ANTHONY BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CAHILL RD STE 204
BRANSON MO
65616-1911
US

IV. Provider business mailing address

PO BOX 505673
SAINT LOUIS MO
63150-5673
US

V. Phone/Fax

Practice location:
  • Phone: 417-335-7222
  • Fax: 417-335-7224
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2024008945
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: