Basic Information
| Provider Information | |||||||||
| NPI: | 1992743702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 KERNAN DR | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212076665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104487112 | ||||||||
| FaxNumber: | 4104486296 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 KERNAN DR | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212076665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104487112 | ||||||||
| FaxNumber: | 4104486296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 10/14/2013 | ||||||||
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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 | 207X00000X | D0060491 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | D0060491 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0114X | D0060491 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0117X | D0060491 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X | D0060491 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X | D0060491 | MD | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0801X | D0060491 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | 402869400 | 05 | MD | MEDICAID | 1992743702 | 01 | MD | NPI | OTHER |