Provider Demographics
NPI:1790734143
Name:VINCENT, BENNIE RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNIE
Middle Name:RAY
Last Name:VINCENT
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 1:9308 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-8055
Mailing Address - Country:US
Mailing Address - Phone:423-290-8792
Mailing Address - Fax:
Practice Address - Street 1:2080 CHAMBLISS AVE NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3894
Practice Address - Country:US
Practice Address - Phone:423-472-6219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055466207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52153553002OtherBCBS-GA PROVIDER ID #
GA52153553002OtherBCBS-GA PROVIDER ID #
GA05BDKNOMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID #