Provider Demographics
NPI:1205117611
Name:BRUCE C. BENNETT, MD, LLC
Entity type:Organization
Organization Name:BRUCE C. BENNETT, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-439-9088
Mailing Address - Street 1:4531 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3285
Mailing Address - Country:US
Mailing Address - Phone:307-439-9088
Mailing Address - Fax:
Practice Address - Street 1:1020 E 2ND ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2946
Practice Address - Country:US
Practice Address - Phone:307-265-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7871A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty