Basic Information
| Provider Information | |||||||||
| NPI: | 1477545754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9203 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049159203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028959627 | ||||||||
| FaxNumber: | 5028958977 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 KRESGE WAY STE 308 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028958911 | ||||||||
| FaxNumber: | 5028958977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 208M00000X | 41725 | KY | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 41725 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200448900 | 05 | IN | MEDICAID | P00049026 | 01 | IN | RAILROAD MEDICARE PROV# | OTHER | 000063095G | 01 | KY | HUMANA | OTHER | 64117005 | 05 | KY | MEDICAID | 000000300382 | 01 | IN | ANTHEM PROV# | OTHER | 000000548736 | 01 | KY | ANTHEM | OTHER | 352154103 | 01 | UNITED HEALTHCARE PROV | OTHER |