Provider Demographics
NPI:1194033977
Name:EDWARD H BENJAMIN MD PC
Entity Type:Organization
Organization Name:EDWARD H BENJAMIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-741-2531
Mailing Address - Street 1:115 ELM ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3712
Mailing Address - Country:US
Mailing Address - Phone:860-741-2531
Mailing Address - Fax:860-745-7587
Practice Address - Street 1:115 ELM ST
Practice Address - Street 2:SUITE 205
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3712
Practice Address - Country:US
Practice Address - Phone:860-741-2531
Practice Address - Fax:860-745-7587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT021127174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B39475Medicare UPIN