Basic Information
| Provider Information | |||||||||
| NPI: | 1326085051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7687 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652057687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738822259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 402 KEENE ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734996084 | ||||||||
| FaxNumber: | 5734996088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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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 | 207V00000X | MDR2H46 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 6642 | 01 | MO | BLUE SHIELD | OTHER | 6642 | 01 | MO | BLUE CHOICE | OTHER | 126944 | 01 | MO | HEALTHLINK | OTHER | 704051 | 01 | MO | UNITED HEALTHCARE | OTHER | 202817706 | 05 | MO | MEDICAID | 2086348001 | 01 | MO | KANSAS MEDICAID | OTHER |