1063551703 NPI number — MR. ERIC BENINGHOF PHYSICIAN ASSISTANT

Table of content: MR. ERIC BENINGHOF PHYSICIAN ASSISTANT (NPI 1063551703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063551703 NPI number — MR. ERIC BENINGHOF PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENINGHOF
Provider First Name:
ERIC
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
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:
1063551703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 HILLSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERONA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07044-1410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-784-4515
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
177 FORT WASHINGTON AVE
Provider Second Line Business Practice Location Address:
MHB 7GN-435
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10032-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-342-1311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2007

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: 363AS0400X , with the licence number:  005945 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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