Provider Demographics
NPI:1750326724
Name:BENNETT, FREEMAN T (MD)
Entity Type:Individual
Prefix:DR
First Name:FREEMAN
Middle Name:T
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 1:1203 LINDEN PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2102
Mailing Address - Country:US
Mailing Address - Phone:601-594-6997
Mailing Address - Fax:888-506-2638
Practice Address - Street 1:1203 LINDEN PL
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2102
Practice Address - Country:US
Practice Address - Phone:601-594-6997
Practice Address - Fax:888-506-2638
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14442207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015768Medicaid
PROVIDER NO. 8EB240OtherCMS
MS01888820Medicaid
MSG55247Medicare UPIN
TX8EB243Medicare PIN
TX8EB240Medicare PIN
PROVIDER NO. 8EB240OtherCMS
MS01888820Medicaid
TX8EB242Medicare PIN