Provider Demographics
NPI:1407970809
Name:BENNER MEDICAL GROUP PA
Entity Type:Organization
Organization Name:BENNER MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MYRON
Authorized Official - Last Name:BENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-866-0080
Mailing Address - Street 1:PO BOX 62211
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264
Mailing Address - Country:US
Mailing Address - Phone:301-866-0080
Mailing Address - Fax:301-866-0010
Practice Address - Street 1:20945 GREAT MILLS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-4369
Practice Address - Country:US
Practice Address - Phone:301-866-0080
Practice Address - Fax:301-866-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD468851100Medicaid
MD133606Medicare PIN
DC406916Medicare PIN