Provider Demographics
NPI:1073718169
Name:AUBERGINE, BENITO W (MD)
Entity Type:Individual
Prefix:DR
First Name:BENITO
Middle Name:W
Last Name:AUBERGINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:
Other - Last Name:STULL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:1200 S COLUMBIA RD - ALTRU HOSPITAL
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121374207P00000X
WI53450-020207P00000X
MN57475207P00000X
ND11216207P00000X
WI53450-20207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361213741Medicaid
WI1073718169Medicaid