Provider Demographics
NPI:1770597528
Name:BENNETT, JEFFERY RUSTEN (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:RUSTEN
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:PO BOX 2363
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2363
Mailing Address - Country:US
Mailing Address - Phone:843-724-2154
Mailing Address - Fax:317-663-6054
Practice Address - Street 1:316 CALHOUN ST
Practice Address - Street 2:ATTN: RADIOLOGY DEPARTMENT
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1113
Practice Address - Country:US
Practice Address - Phone:843-724-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-003412085R0202X
SC298272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC298270Medicaid
SCP00403138OtherRR MCARE
SC298270Medicaid
SCAA19574467Medicare PIN