Basic Information
| Provider Information | |||||||||
| NPI: | 1174542872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENSON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5052 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012685995 | ||||||||
| FaxNumber: | 6012647426 | ||||||||
| Practice Location | |||||||||
| Address1: | 5052 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012685995 | ||||||||
| FaxNumber: | 6012647426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 10608 | MS | Y | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
ID Information
| ID | Type | State | Issuer | Description | 00117051 | 05 | MS | MEDICAID | P00470762 | 01 | MS | RAILROAD MEDICARE | OTHER |