Provider Demographics
NPI:1184658056
Name:BENNETT, IVAN R (PA)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:R
Last Name:BENNETT
Suffix:
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5506
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:7798 DISCOVERY DR.
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-6542
Practice Address - Country:US
Practice Address - Phone:513-939-2263
Practice Address - Fax:513-874-4579
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002463363AS0400X
OH50002463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100001230Medicaid
OHBEPA27101OtherMEDICARE CGS
KY7100001230Medicaid
OHQ70377Medicare UPIN