Healthcare Provider Details

I. General information

NPI: 1831118199
Provider Name (Legal Business Name): MATTHEW THOMAS BENNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 HARRISON ST 2ND FL
JOHNSON CITY NY
13790-2120
US

IV. Provider business mailing address

33 LEWIS RD 2ND FL
BINGHAMTON NY
13905-1048
US

V. Phone/Fax

Practice location:
  • Phone: 607-748-7468
  • Fax: 607-754-6130
Mailing address:
  • Phone: 607-729-8156
  • Fax: 607-729-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number230023
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: