1295834752 NPI number — MR. MARWYN GARIBAY BENEMERITO OTR/L

Table of content: MR. MARWYN GARIBAY BENEMERITO OTR/L (NPI 1295834752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295834752 NPI number — MR. MARWYN GARIBAY BENEMERITO OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENEMERITO
Provider First Name:
MARWYN
Provider Middle Name:
GARIBAY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
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:
1295834752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
895 WILLOW TREE CIR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CORDOVA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38018-3106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-309-5219
Provider Business Mailing Address Fax Number:
901-309-5265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
895 WILLOW TREE CIR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CORDOVA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38018-3106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-309-5219
Provider Business Practice Location Address Fax Number:
901-309-5265
Provider Enumeration Date:
09/21/2006

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: 225X00000X , with the licence number:  955 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4128796 . This is a "BCBS OF TN PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4290875 . This is a "BCBS PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7536487 . This is a "AETNA PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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