1932104007 NPI number — DR. KENNETH JAMES BENJAMIN D.P.M.

Table of content: SHANE LOUIS PENNISON APRN, FNP-C (NPI 1063142412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932104007 NPI number — DR. KENNETH JAMES BENJAMIN D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENJAMIN
Provider First Name:
KENNETH
Provider Middle Name:
JAMES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1932104007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/18/2006
NPI Reactivation Date:
04/04/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
198 THOMAS JOHNSON DR
Provider Second Line Business Mailing Address:
STE 4
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21702-4398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-695-9669
Provider Business Mailing Address Fax Number:
301-695-0346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
198 THOMAS JOHNSON DR
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21702-4398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-695-9669
Provider Business Practice Location Address Fax Number:
301-695-0346
Provider Enumeration Date:
06/16/2005

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: 213ES0103X , with the licence number:  00592 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 998448 . This is a "AETNA HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K374 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 4081479 . This is a "AETNA HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9502 . This is a "BLUE CROSS BLUE CHOICE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 385141 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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