Provider Demographics
NPI:1043254253
Name:BENNETT, KENNETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5678
Mailing Address - Fax:601-984-5638
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE DIVISION OF CARDIOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5678
Practice Address - Fax:601-984-5638
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05908207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1552470Medicaid
AL180445Medicaid
MSRR 060049688OtherRAILROAD
MS00119359Medicaid
MSP00462157OtherRAILROAD MEDICARE PTAN
MS00119359Medicaid
MS302I067047Medicare PIN
MS512I110050Medicare PIN