Provider Demographics
NPI:1164498903
Name:BENNIE, PETER JR (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BENNIE
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5000
Mailing Address - Country:US
Mailing Address - Phone:404-847-9999
Mailing Address - Fax:404-531-8466
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 700
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5000
Practice Address - Country:US
Practice Address - Phone:404-847-9999
Practice Address - Fax:404-531-8466
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP06577Medicare UPIN
GA97BBFTMMedicare PIN