Provider Demographics
NPI:1366482192
Name:BENJAMIN Z BENNOV MD PC
Entity Type:Organization
Organization Name:BENJAMIN Z BENNOV MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:Z
Authorized Official - Last Name:BENNOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-671-1484
Mailing Address - Street 1:9630 BUSTLETON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3102
Mailing Address - Country:US
Mailing Address - Phone:215-671-1484
Mailing Address - Fax:215-671-1485
Practice Address - Street 1:9630 BUSTLETON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3102
Practice Address - Country:US
Practice Address - Phone:215-671-1484
Practice Address - Fax:215-671-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017478320002Medicaid
PA026103Medicare ID - Type Unspecified