Provider Demographics
NPI:1144455023
Name:BENNETT, SEAN H (IDMT)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:H
Last Name:BENNETT
Suffix:
Gender:M
Credentials:IDMT
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 608
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-0608
Mailing Address - Country:US
Mailing Address - Phone:304-257-4922
Mailing Address - Fax:304-257-2422
Practice Address - Street 1:739 NORTH FORK HIGHWAY
Practice Address - Street 2:GRANT COUNTY HEALTH DEPARTMENT
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-0608
Practice Address - Country:US
Practice Address - Phone:304-257-4922
Practice Address - Fax:304-257-2422
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians