=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487633483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA C BENNETT PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2006
-----------------------------------------------------
Last Update Date | 09/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 186 KIMEL PARK DR ATTN: WINSTON-SALEM CARDIOLOGY
-----------------------------------------------------
City | WINSTON-SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-6946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-277-2000
-----------------------------------------------------
Fax | 336-277-2050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 FRONTIS PLAZA BLVD STE 200 (ATTN) FORSYTH MEDICAL GROUP
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-277-2435
-----------------------------------------------------
Fax | 336-277-9275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 103420
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------