Basic Information
| Provider Information | |||||||||
| NPI: | 1053769893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | JOE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10452 SILVERDALE WAY NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983839411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603077300 | ||||||||
| FaxNumber: | 3603077304 | ||||||||
| Practice Location | |||||||||
| Address1: | 10452 SILVERDALE WAY NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983839411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603077300 | ||||||||
| FaxNumber: | 3603077304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2016 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 295105 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD61171597 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.