Provider Demographics
NPI:1700845112
Name:INDEPENDENCE MEDICAL, PA
Entity type:Organization
Organization Name:INDEPENDENCE MEDICAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-622-8272
Mailing Address - Street 1:1209 FALLS BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8935
Mailing Address - Country:US
Mailing Address - Phone:919-544-4747
Mailing Address - Fax:919-544-0104
Practice Address - Street 1:515 BARBOUR RD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-7698
Practice Address - Country:US
Practice Address - Phone:919-544-4747
Practice Address - Fax:919-544-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36493207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDA5493OtherMEDICARE RAILROAD
NC891028PMedicaid
NC1028PMedicaid
NCP00062870OtherMEDICARE RAILROAD
NCDA5493OtherMEDICARE RAILROAD