=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922218627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT FORTIER BENSEN M.D.,N.D.,CCN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 SECURITY SQ
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39507-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-897-2337
-----------------------------------------------------
Fax | 228-897-2316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 445 SECURITY SQ P. O. BOX 6055
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39506-6055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-897-2337
-----------------------------------------------------
Fax | 228-897-2316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 13456
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 018864
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------