Provider Demographics
NPI:1619979382
Name:BENNINGER, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:BENNINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY
Mailing Address - Street 2:STE 129
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5132
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:4121 DUTCHMANS LN
Practice Address - Street 2:SUITE #101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4707
Practice Address - Country:US
Practice Address - Phone:502-897-2531
Practice Address - Fax:502-896-5863
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY22073207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
50000083OtherPASSPORT
KY64220734Medicaid
000000247202OtherANTHEM
C73289Medicare UPIN
160006194Medicare PIN
000000247202OtherANTHEM