=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982773610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CECIL FITZ ALBERT BENNETT JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 10/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 HOSPITAL RD
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30263-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-251-5540
-----------------------------------------------------
Fax | 770-251-5502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51 HOSPITAL RD
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30263-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-251-5540
-----------------------------------------------------
Fax | 770-487-9974
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | GA48844
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 048844
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------