Individual
IVAN R BENNETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
7798 DISCOVERY DR., WEST CHESTER, OH 45069-6542
(513) 939-2263
(513) 874-4579
Mailing address
PO BOX 636256 CENTRAL CREDENTIALING, CINCINNATI, OH 45263-6256
(513) 585-5506
(513) 585-5511
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
50002463
OH
363AS0400X
Surgical Physician Assistant
50-002463
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100001230
—
KY
01
—
BEPA27101
MEDICARE CGS
OH
Enumeration date
07/10/2006
Last updated
02/26/2018
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