Provider Demographics
NPI:1104854553
Name:SHORT, BENNY LEE (MD)
Entity Type:Individual
Prefix:
First Name:BENNY
Middle Name:LEE
Last Name:SHORT
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 1:200 W ROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-7221
Mailing Address - Country:US
Mailing Address - Phone:620-371-7300
Mailing Address - Fax:620-371-7304
Practice Address - Street 1:200 W ROSS BLVD
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-7221
Practice Address - Country:US
Practice Address - Phone:620-371-7300
Practice Address - Fax:620-371-7304
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28386207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS102645OtherBC/BS
KS100354710CMedicaid
KS100354710IMedicaid
KS100354710HMedicaid
KS100354710HMedicaid
KSKA1000021Medicare PIN
KS102645Medicare ID - Type Unspecified