Healthcare Provider Details

I. General information

NPI: 1386645703
Provider Name (Legal Business Name): EDWARD V BENNETT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NEW SCOTLAND AVE # MC192
ALBANY NY
12208-3403
US

IV. Provider business mailing address

50 NEW SCOTLAND AVE # MC192
ALBANY NY
12208-3403
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-9777
  • Fax: 518-262-9778
Mailing address:
  • Phone: 518-262-9777
  • Fax: 518-262-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number140950-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: