Provider Demographics
NPI:1982786471
Name:BENNE, MICHAEL GEORGE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GEORGE
Last Name:BENNE
Suffix:JR
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 1359
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608
Mailing Address - Country:US
Mailing Address - Phone:417-683-4831
Mailing Address - Fax:417-683-1602
Practice Address - Street 1:504 NW 10TH AVE.
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608
Practice Address - Country:US
Practice Address - Phone:417-683-4831
Practice Address - Fax:417-683-1602
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000034580207P00000X
MO2009035422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4120779OtherBCBS OF TN
TN3337428Medicaid
FL71374YMedicare PIN
TND65538Medicare UPIN
TN3337428Medicaid