Provider Demographics
NPI:1174657084
Name:BENNEYWORTH, BRIAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:D
Last Name:BENNEYWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:ROC 4270
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-7208
Practice Address - Fax:317-274-3442
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010709552080P0203X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01751302OtherRR MEDICARE
IN201061570Medicaid
INP01751302OtherRR MEDICARE
INM400071448Medicare PIN