Basic Information
| Provider Information | |||||||||
| NPI: | 1306136460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | GROUP HEALTH ASSOCIATES | ||||||||
| Address2: | 6010 S. MASON MONTGOMERY ROAD | ||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450403706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132467000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6010 S MASON MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450403706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1324670005 | ||||||||
| FaxNumber: | 5132046355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 09/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35122871 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0114738 | 05 | OH | MEDICAID |