Provider Demographics
NPI:1083659361
Name:BENEZE MEDICAL GROUP
Entity Type:Organization
Organization Name:BENEZE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KEATING
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:928-758-7700
Mailing Address - Street 1:3003 HIGHWAY 95
Mailing Address - Street 2:SUITE G73
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7860
Mailing Address - Country:US
Mailing Address - Phone:928-758-7700
Mailing Address - Fax:928-758-5700
Practice Address - Street 1:3003 HIGHWAY 95
Practice Address - Street 2:SUITE G73
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7860
Practice Address - Country:US
Practice Address - Phone:928-758-7700
Practice Address - Fax:928-758-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR09321Medicare UPIN
AZE80456Medicare UPIN
AZ62740Medicare ID - Type UnspecifiedMEDICARE GROUP BILLING
AZR15868Medicare UPIN