Healthcare Provider Details

I. General information

NPI: 1972410413
Provider Name (Legal Business Name): ROGER TODD BENNETT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 HOSPITAL DR
MADISON TN
37115-5030
US

IV. Provider business mailing address

710 W COLLEGE ST APT 2
DICKSON TN
37055-1767
US

V. Phone/Fax

Practice location:
  • Phone: 615-732-7679
  • Fax:
Mailing address:
  • Phone: 615-973-1662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number233561
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: