Provider Demographics
NPI:1245292556
Name:BENNETT, PAULA RICKARD (MD)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:RICKARD
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2121
Mailing Address - Country:US
Mailing Address - Phone:570-251-6500
Mailing Address - Fax:570-253-8195
Practice Address - Street 1:1839 FAIR AVE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-2121
Practice Address - Country:US
Practice Address - Phone:570-251-6500
Practice Address - Fax:570-253-8195
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036509E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
002308OtherFIRST PRIORITY HEALTH PIN
51467OtherGEISINGER HEALTH PLAN PIN
PA001151420Medicaid
NY01128981Medicaid
NY01128981Medicaid
PA010033444Medicare PIN
PA174570Medicare PIN