MEDICARE: DR. GREGORY DANIEL BENNETT 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	207P00000X	Emergency Medicine Physician	080265	GA
2	207R00000X	Internal Medicine Physician	80265	GA

General Provider Information

NPI Number	:	1366651507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY DANIEL BENNETT MD

Provider Business Mailing Address
First Line	:	200 CORPORATE BLVD
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-3870
Country	:	US
Telephone Number	:	800-893-9698
Fax Number	:

Provider Business Practice Location Address
First Line	:	5585 THOMASTON RD STE A600
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31220-8200
Country	:	US
Telephone Number	:	478-219-9514
Fax Number	:	478-259-2836

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	08/31/2021

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