1760415640 NPI number — PAUL D BENINGA CRNA

Table of content: PAUL D BENINGA CRNA (NPI 1760415640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760415640 NPI number — PAUL D BENINGA CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENINGA
Provider First Name:
PAUL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760415640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5045
Provider Second Line Business Mailing Address:
C.B.O. PROV ENROLLMT
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-2754
Provider Business Mailing Address Fax Number:
605-322-2727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 S CLIFF AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-2754
Provider Business Practice Location Address Fax Number:
605-322-2727
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R023547 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5750954 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5750955 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006965500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 013K7BE . This is a "MN BCBS PROV#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 460224743-48 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0006253 . This is a "SD BLUE CROSS IND #" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0030016 . This is a "SD BLUE CROSS GROUP#" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0573493 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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