Basic Information
| Provider Information | |||||||||
| NPI: | 1891774675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTON | ||||||||
| FirstName: | ROLAND | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568681 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 E RING RD | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456389610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405349830 | ||||||||
| FaxNumber: | 7405349832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35077695 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 077695 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.077695 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 35913 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 35913 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000380359 | 01 | KY | ANTHEM BCBS | OTHER | 1801701000 | 05 | WV | MEDICAID | 64022619 | 05 | KY | MEDICAID | 000000598423 | 01 | KY | ANTHEM BCBS | OTHER | 2190276 | 05 | OH | MEDICAID |