Provider Demographics
NPI:1477839702
Name:CHARLES W BENNETT MD LLC
Entity Type:Organization
Organization Name:CHARLES W BENNETT MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-326-6344
Mailing Address - Street 1:11845 HG TRUEMAN RD
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-2855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11845 HG TRUEMAN RD
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657-2855
Practice Address - Country:US
Practice Address - Phone:410-326-6344
Practice Address - Fax:410-326-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD43306174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty