Basic Information
| Provider Information | |||||||||
| NPI: | 1114191871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT- GITTENS | ||||||||
| FirstName: | RAQUEL | ||||||||
| MiddleName: | LISA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9247 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319089247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063227884 | ||||||||
| FaxNumber: | 7066602118 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 19TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319011528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063227884 | ||||||||
| FaxNumber: | 7066602118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 001688 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 70713 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 202I061193 | 01 | GA | MEDICARE PTAN | OTHER | 003140208B | 05 | GA | MEDICAID |