Healthcare Provider Details

I. General information

NPI: 1184658056
Provider Name (Legal Business Name): IVAN R BENNETT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7798 DISCOVERY DR.
WEST CHESTER OH
45069-6542
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-939-2263
  • Fax: 513-874-4579
Mailing address:
  • Phone: 513-585-5506
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50-002463
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50002463
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: