Provider Demographics
NPI:1316018260
Name:BENNER, MARIAN (MD)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:BENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8560
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3979
Practice Address - Country:US
Practice Address - Phone:207-907-1550
Practice Address - Fax:207-907-3052
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEMD16834207R00000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME528951300Medicaid
ME528951300Medicaid