Provider Demographics
NPI:1255315560
Name:FANN, BENJAMIN B (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:B
Last Name:FANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 STATE FARM RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5391
Mailing Address - Country:US
Mailing Address - Phone:828-386-1001
Mailing Address - Fax:828-358-1317
Practice Address - Street 1:838 STATE FARM RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5391
Practice Address - Country:US
Practice Address - Phone:828-386-1001
Practice Address - Fax:828-358-1317
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33034208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC07070484OtherUHC
2337582OtherGROUP
NC31142OtherBCBS
NC7931142Medicaid
NC2158475BMedicare ID - Type Unspecified
C73333Medicare UPIN