1922187947 NPI number — TOM BENOLERAO PT

Table of content: TOM BENOLERAO PT (NPI 1922187947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922187947 NPI number — TOM BENOLERAO PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENOLERAO
Provider First Name:
TOM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1922187947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2053 W 1820 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84770-4856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-464-6382
Provider Business Mailing Address Fax Number:
845-464-6382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 N 1680 E
Provider Second Line Business Practice Location Address:
PHYSICAL THERAPY DEPT
Provider Business Practice Location Address City Name:
SAINT GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84790-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-464-6382
Provider Business Practice Location Address Fax Number:
845-464-6382
Provider Enumeration Date:
11/02/2006

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: 225100000X , with the licence number:  10586212-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1000043901 . This is a "AFFINITY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 173774P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: Q13E71 . This is a "EMPIRE BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02566383 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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