Healthcare Provider Details

I. General information

NPI: 1437996097
Provider Name (Legal Business Name): MIA EUGENIA BENNETT CCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/11/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST. RITA'S MEDICAL CENTER 730 W MARKET ST
LIMA OH
45801
US

IV. Provider business mailing address

9220 WORTHINGTON RD APT 342
WESTERVILLE OH
43082-7271
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-3361
  • Fax:
Mailing address:
  • Phone: 614-783-4921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number049010
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: