Basic Information
| Provider Information | |||||||||
| NPI: | 1396777421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENTON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 871 COLE CT | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704337904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044326458 | ||||||||
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| Practice Location | |||||||||
| Address1: | 95 E FAIRWAY DR | ||||||||
| Address2: | LAKEVIEW MEDICAL CENTER | ||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704337500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858674000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | 199991 | LA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1063941 | 05 | LA | MEDICAID |