MEDICARE: BENNIE R. WHITE JR. 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	207Q00000X	Family Medicine Physician	056245	GA

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	:	1376575225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENNIE R. WHITE JR. MD

Provider Business Mailing Address
First Line	:	794 MCDONOUGH RD
Second Line	:	SUITE 105
City	:	JACKSON
State	:	GA
Zip	:	30233-1572
Country	:	US
Telephone Number	:	770-775-2341
Fax Number	:	770-775-3668

Provider Business Practice Location Address
First Line	:	794 MCDONOUGH RD
Second Line	:	SUITE 105
City	:	JACKSON
State	:	GA
Zip	:	30233-1572
Country	:	US
Telephone Number	:	770-775-2341
Fax Number	:	770-775-3668

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	12/18/2012

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