=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790734143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENNIE RAY VINCENT M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2080 CHAMBLISS AVE NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37311-3894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-472-6219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9308 PINE RIDGE RD
-----------------------------------------------------
City | OOLTEWAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37363-8055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-290-8792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 055466
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------