1023071503 NPI number — ERNETTE YVONNE BENSON-FOULK MD

Table of content: ERNETTE YVONNE BENSON-FOULK MD (NPI 1023071503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023071503 NPI number — ERNETTE YVONNE BENSON-FOULK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENSON-FOULK
Provider First Name:
ERNETTE
Provider Middle Name:
YVONNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1023071503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6345 CENTER DR
Provider Second Line Business Mailing Address:
BUILDING 14
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23502-4105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-461-4027
Provider Business Mailing Address Fax Number:
757-461-8821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6345 CENTER DR
Provider Second Line Business Practice Location Address:
BUILDING 14
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23502-4105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-461-4027
Provider Business Practice Location Address Fax Number:
757-461-8821
Provider Enumeration Date:
04/07/2006

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: 208000000X , with the licence number:  0101054489 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1023071503 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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