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General NPI Number Information
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NPI Number | 1023566007
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Entity Type | Individual
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Provider Name | BENTON STOUTAMIRE CNIM
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Gender | Male
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Dates
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Enumeration Date | 09/19/2016
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Last Update Date | 10/28/2021
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Provider Practice Location Address
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Address Line | 420 CHARTER BLVD STE 402A
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City | MACON
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State | GA
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Zip | 31210-4854
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Country | US
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Telephone | 478-273-3831
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Fax | 303-922-4640
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Provider Business Mailing Address
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Address Line | 420 CHARTER BLVD STE 402A
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City | MACON
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State | GA
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Zip | 31210-4854
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Country | US
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Telephone | 478-273-3831
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Fax | 855-940-0206
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZE0600X
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Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
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License Number |
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License Number State |
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