Basic Information
| Provider Information | |||||||||
| NPI: | 1316942469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNIE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 29TH AVE N | ||||||||
| Address2: | STE 202 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 29TH AVE N | ||||||||
| Address2: | STE 202 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 08/20/2008 | ||||||||
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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 | 174400000X | 021631 | TN | N | Other Service Providers | Specialist | 207L00000X | 21631 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 610596345A | 05 | GA | MEDICAID | 3058871 | 05 | TN | MEDICAID | 009991815 | 05 | AL | MEDICAID | 3029953 | 01 | TN | BCBS PROVIDER NUMBER | OTHER | 64911480 | 05 | KY | MEDICAID |