Basic Information
| Provider Information | |||||||||
| NPI: | 1184658056 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 CENTRAL CREDENTIALING | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855506 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 7798 DISCOVERY DR. | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450696542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139392263 | ||||||||
| FaxNumber: | 5138744579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50-002463 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 50002463 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100001230 | 05 | KY | MEDICAID | BEPA27101 | 01 | OH | MEDICARE CGS | OTHER |