MEDICARE: DR. JEFFREY GREEN BENNION M.D.

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	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	274201-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7054	OTHER	ID	IDAHO BOARD OF PHARMACY
2	274201-9915	OTHER	UT	UTAH CONTROLLED SUBSTANCE
3	M-6924	OTHER	ID	IDAHO STATE LICENSE

General Provider Information

NPI Number	:	1396731469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY GREEN BENNION M.D.

Provider Business Mailing Address
First Line	:	2245 N 400 E
Second Line	:	STE 301
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-1892
Country	:	US
Telephone Number	:	435-753-7880
Fax Number	:	435-753-5845

Provider Business Practice Location Address
First Line	:	2245 N 400 E
Second Line	:	STE 301
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-1892
Country	:	US
Telephone Number	:	435-753-7880
Fax Number	:	435-753-5845

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

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	03/07/2023

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