1376075804 NPI number — BENJAMIN PHYSICAL MEDICINE, PLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376075804 NPI number — BENJAMIN PHYSICAL MEDICINE, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENJAMIN PHYSICAL MEDICINE, PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1376075804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
373 BLAIR PARK RD.
Provider Second Line Business Mailing Address:
STE 206
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-522-9699
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
373 BLAIR PARK RD
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05495-7998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-522-9699
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BENJAMIN
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
EVAN
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
802-522-9699

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  420010625 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 59537 . This is a "VERMONT BC/BS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 44146784 . This is a "CIGNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 3547305 . This is a "CIGNA" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 02502692 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1009844 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30204569 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0233J1 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 699468 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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