Provider Demographics
NPI:1275517476
Name:BICKNELL, BENNETT W (MD)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:W
Last Name:BICKNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 PRIMACY PKWY
Mailing Address - Street 2:SUITE 241
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5745
Mailing Address - Country:US
Mailing Address - Phone:901-725-5846
Mailing Address - Fax:
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:316-685-6091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24729207L00000X
MS22953207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3075049OtherBLUE CROSS BLUE SHIELD
TN3080496Medicaid
MS00117572Medicaid
9823478OtherCIGNA
AN99147OtherUNITED HEALTHCARE
AR97346OtherAR BLUE CROSS BLUE SHIELD
AR130290001Medicaid
MO208593806Medicaid
AR97346OtherAR BLUE CROSS BLUE SHIELD