Provider Demographics
NPI:1063597235
Name:THOMAS W. BENNINGER PLLC
Entity type:Organization
Organization Name:THOMAS W. BENNINGER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO MEMBER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-897-2531
Mailing Address - Street 1:4121 DUTCHMANS LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4707
Mailing Address - Country:US
Mailing Address - Phone:502-897-2531
Mailing Address - Fax:502-896-5863
Practice Address - Street 1:4121 DUTCHMANS LN
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4707
Practice Address - Country:US
Practice Address - Phone:502-897-9416
Practice Address - Fax:502-896-8660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22073207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000247202OtherANTHEM
KY64220734Medicaid
KY50000083OtherPASSPORT
KY50000083OtherPASSPORT
KY64220734Medicaid