Provider Demographics
NPI:1154318384
Name:BENTON, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:BENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 PROVIDENCE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1468
Mailing Address - Country:US
Mailing Address - Phone:704-749-5800
Mailing Address - Fax:704-749-5819
Practice Address - Street 1:200 PROVIDENCE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1468
Practice Address - Country:US
Practice Address - Phone:704-749-5800
Practice Address - Fax:704-749-5819
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC28399207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8915172Medicaid
NC204756BMedicare PIN
NCC82792Medicare UPIN