Healthcare Provider Details

I. General information

NPI: 1801888797
Provider Name (Legal Business Name): SUSAN RENE BENSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MEDICAL PARK RD STE 200
MOORESVILLE NC
28117-8578
US

IV. Provider business mailing address

650 SIGNAL HILL DRIVE EXT PO BOX 1845
STATESVILLE NC
28625-4353
US

V. Phone/Fax

Practice location:
  • Phone: 704-696-2085
  • Fax: 704-660-0194
Mailing address:
  • Phone: 704-696-2085
  • Fax: 704-660-0194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200200492
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: