Provider Demographics
NPI:1114168408
Name:MATTHEW A. BENNETT MD PLLC
Entity Type:Organization
Organization Name:MATTHEW A. BENNETT MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-332-2300
Mailing Address - Street 1:624 RIVER RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-6563
Mailing Address - Country:US
Mailing Address - Phone:716-332-2300
Mailing Address - Fax:716-332-2280
Practice Address - Street 1:624 RIVER RD
Practice Address - Street 2:SUITE #1
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-6563
Practice Address - Country:US
Practice Address - Phone:716-332-2300
Practice Address - Fax:716-332-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250570261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care