MEDICARE: DR. LISA ANN BENNING 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	207R00000X	Internal Medicine Physician	036078400	IL
2	208M00000X	Hospitalist Physician	036078400	IL

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	:	1689672289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA ANN BENNING M.D.

Provider Business Mailing Address
First Line	:	1025 S 6TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-2403
Country	:	US
Telephone Number	:	217-528-7541
Fax Number	:	217-528-8962

Provider Business Practice Location Address
First Line	:	701 N 1ST ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62702-3757
Country	:	US
Telephone Number	:	217-528-7541
Fax Number	:	217-753-0815

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	09/25/2013

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