Provider Demographics
NPI:1386645703
Name:BENNETT, EDWARD V JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:V
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:50 NEW SCOTLAND AVE # MC192
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3403
Mailing Address - Country:US
Mailing Address - Phone:518-262-9777
Mailing Address - Fax:518-262-9778
Practice Address - Street 1:50 NEW SCOTLAND AVE # MC192
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3403
Practice Address - Country:US
Practice Address - Phone:518-262-9777
Practice Address - Fax:518-262-9778
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-06-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY140950-1208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00803627Medicaid
NY00803627Medicaid