Provider Demographics
NPI:1235115148
Name:BENNETT, SHIRLEY (MD)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
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 638269
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:440-816-5390
Mailing Address - Fax:440-816-6438
Practice Address - Street 1:7255 OLD OAK BLVD
Practice Address - Street 2:#C-202
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3329
Practice Address - Country:US
Practice Address - Phone:440-816-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-055857207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0873309Medicaid
OH160017293OtherRAILROAD MEDICARE PIN
OH0708991Medicare PIN
OH160017293OtherRAILROAD MEDICARE PIN