MEDICARE: BENJAMIN G. BENNER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	11695	OK
2	207T00000X	Neurological Surgery Physician	E0810	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336137967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN G. BENNER MD

Provider Business Mailing Address
First Line	:	6767 S YALE AVE
Second Line	:	SUITE A
City	:	TULSA
State	:	OK
Zip	:	74136-3302
Country	:	US
Telephone Number	:	918-492-7587
Fax Number	:	918-491-3542

Provider Business Practice Location Address
First Line	:	6767 S YALE AVE
Second Line	:	SUITE A
City	:	TULSA
State	:	OK
Zip	:	74136-3302
Country	:	US
Telephone Number	:	918-492-7587
Fax Number	:	918-491-3542

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	12/16/2009

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