Provider Demographics
NPI:1538161468
Name:BENNER, JOHN NOLT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:NOLT
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 1:1425 PHILADELPHIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1386
Mailing Address - Country:US
Mailing Address - Phone:717-261-4194
Mailing Address - Fax:717-261-4319
Practice Address - Street 1:1425 PHILADELPHIA AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1386
Practice Address - Country:US
Practice Address - Phone:717-261-4194
Practice Address - Fax:717-261-4319
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071869E207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB33713Medicare UPIN
665949Medicare PIN
PA031128KBMMedicare ID - Type Unspecified