Provider Demographics
NPI:1932175163
Name:BENNERT, KEITH WILKINSON (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WILKINSON
Last Name:BENNERT
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 100559
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-0559
Mailing Address - Country:US
Mailing Address - Phone:843-664-4300
Mailing Address - Fax:843-664-4308
Practice Address - Street 1:2000 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3449
Practice Address - Country:US
Practice Address - Phone:252-637-9298
Practice Address - Fax:252-633-8941
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36652207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8914895Medicaid
01078OtherBCBS GRP #
F55503Medicare UPIN
NC8914895Medicaid