Provider Demographics
NPI:1366427841
Name:BENNETT, JON MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:MICHAEL
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 N KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-3055
Mailing Address - Country:US
Mailing Address - Phone:843-449-3381
Mailing Address - Fax:843-449-9721
Practice Address - Street 1:7900 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-3055
Practice Address - Country:US
Practice Address - Phone:843-449-3381
Practice Address - Fax:843-449-9721
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37755207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX74530Medicaid
CACU491ZMedicare PIN
CAAS311YMedicare PIN
CACU491YMedicare PIN
CA00AX74530Medicaid
CAW20A7453BMedicare PIN
CAW20A7453AMedicare PIN