Healthcare Provider Details

I. General information

NPI: 1700845112
Provider Name (Legal Business Name): INDEPENDENCE MEDICAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 BARBOUR RD
SMITHFIELD NC
27577-7698
US

IV. Provider business mailing address

1209 FALLS BRIDGE DR
RALEIGH NC
27614-8935
US

V. Phone/Fax

Practice location:
  • Phone: 919-544-4747
  • Fax: 919-544-0104
Mailing address:
  • Phone: 919-544-4747
  • Fax: 919-544-0104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number36493
License Number StateNC

VIII. Authorized Official

Name: BERNARD L BENNETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 919-622-8272