Provider Demographics
NPI:1699395145
Name:BENNETT, BRYAN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ANDREW
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 CANTON ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:PA
Mailing Address - Zip Code:16947-1452
Mailing Address - Country:US
Mailing Address - Phone:801-520-6994
Mailing Address - Fax:
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-442-1713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61400314207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine