Provider Demographics
NPI:1417126517
Name:BENJAMIN B MASSENBURG IV MD INC
Entity Type:Organization
Organization Name:BENJAMIN B MASSENBURG IV MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MASSENBURG
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:805-563-3011
Mailing Address - Street 1:PO BOX 8488
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-8488
Mailing Address - Country:US
Mailing Address - Phone:805-563-3011
Mailing Address - Fax:
Practice Address - Street 1:221 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2526
Practice Address - Country:US
Practice Address - Phone:808-242-2290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI05627502Medicaid
HIH52779Medicare PIN