Provider Demographics
NPI:1083609531
Name:CORCORAN, BENJAMIN M (MS,PT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:CORCORAN
Suffix:
Gender:M
Credentials:MS,PT
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:B
Other - Last Name:HEMPSTEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-2088
Mailing Address - Country:US
Mailing Address - Phone:802-860-1358
Mailing Address - Fax:802-860-1093
Practice Address - Street 1:115 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-2088
Practice Address - Country:US
Practice Address - Phone:802-860-1358
Practice Address - Fax:802-860-1093
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023544225100000X
VT040-0003806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02278839Medicaid
VT1018180Medicaid
VT1018180Medicaid
NYS94568Medicare UPIN
VT1186801Medicare PIN