Provider Demographics
NPI:1376075804
Name:BENJAMIN PHYSICAL MEDICINE, PLC
Entity Type:Organization
Organization Name:BENJAMIN PHYSICAL MEDICINE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-522-9699
Mailing Address - Street 1:373 BLAIR PARK RD.
Mailing Address - Street 2:STE 206
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495
Mailing Address - Country:US
Mailing Address - Phone:802-522-9699
Mailing Address - Fax:
Practice Address - Street 1:373 BLAIR PARK RD
Practice Address - Street 2:STE 206
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7998
Practice Address - Country:US
Practice Address - Phone:802-522-9699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT420010625261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT59537OtherVERMONT BC/BS
NH44146784OtherCIGNA
VT3547305OtherCIGNA
NY02502692Medicaid
VT1009844Medicaid
NH30204569Medicaid
NY0233J1OtherEMPIRE BC/BS
VT699468OtherMVP
VT699468OtherMVP