Provider Demographics
NPI:1285664730
Name:DALE, BENJAMIN (PAC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:DALE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MEDICAL PARK DR E STE 354
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3469
Mailing Address - Country:US
Mailing Address - Phone:866-546-2124
Mailing Address - Fax:866-546-2124
Practice Address - Street 1:48 MEDICAL PARK DR E STE 354
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3469
Practice Address - Country:US
Practice Address - Phone:866-546-2124
Practice Address - Fax:866-546-2124
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA70363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000042307Medicaid
R75718Medicare UPIN
R75718Medicare UPIN