Provider Demographics
NPI:1841317138
Name:BENNETT, RAY BURNETT (MD)
Entity type:Individual
Prefix:DR
First Name:RAY
Middle Name:BURNETT
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1325 COMMERCE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3582
Mailing Address - Country:US
Mailing Address - Phone:770-692-7575
Mailing Address - Fax:770-692-7570
Practice Address - Street 1:1325 COMMERCE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3582
Practice Address - Country:US
Practice Address - Phone:770-692-7575
Practice Address - Fax:770-692-7570
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA152797525AMedicaid
GA511G700201Medicare PIN
GAI23134Medicare UPIN
511I080251Medicare UPIN
GA152797525AMedicaid
GA202I084391Medicare UPIN
GA08CBCLVMedicare PIN