Provider Demographics
NPI:1093795635
Name:BENNER, ROBERT C (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:C
Last Name:BENNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1744
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04903-1744
Mailing Address - Country:US
Mailing Address - Phone:207-465-4601
Mailing Address - Fax:207-465-4602
Practice Address - Street 1:895 KENNEDY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:ME
Practice Address - Zip Code:04963-4874
Practice Address - Country:US
Practice Address - Phone:207-465-4601
Practice Address - Fax:207-465-4602
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM7240Medicare PIN