Provider Demographics
NPI:1902872435
Name:BENNER, CHARLES MYRON (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MYRON
Last Name:BENNER
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 1:14090 HG TRUEMAN RD STE 2300-710
Mailing Address - Street 2:
Mailing Address - City:SOLOMONS
Mailing Address - State:MD
Mailing Address - Zip Code:20688-3151
Mailing Address - Country:US
Mailing Address - Phone:410-449-6602
Mailing Address - Fax:410-449-6605
Practice Address - Street 1:14090 HG TRUEMAN RD STE 2300-710
Practice Address - Street 2:
Practice Address - City:SOLOMONS
Practice Address - State:MD
Practice Address - Zip Code:20688-3151
Practice Address - Country:US
Practice Address - Phone:410-449-6602
Practice Address - Fax:410-449-6605
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0031563207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD468871600Medicaid
MD468871600Medicaid
DC52970002OtherCAREFIRST DC
MD61278101OtherCAREFIRST MD
DC174423B16Medicare PIN
DC52970002OtherCAREFIRST DC
080139605Medicare ID - Type UnspecifiedRR MEDICARE
MD468871600Medicaid