Basic Information
| Provider Information | |||||||||
| NPI: | 1720287394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNION | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | BLANTON | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268526 | ||||||||
| FaxNumber: | 9209268370 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209264600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5101017192 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 073399 | GA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 72678 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.