Provider Demographics
NPI:1467631762
Name:BENEDICT PODIATRY GROUP
Entity Type:Organization
Organization Name:BENEDICT PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENEDICT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-673-3505
Mailing Address - Street 1:1627 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-2875
Mailing Address - Country:US
Mailing Address - Phone:330-673-3505
Mailing Address - Fax:330-673-4888
Practice Address - Street 1:1627 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-2875
Practice Address - Country:US
Practice Address - Phone:330-673-3505
Practice Address - Fax:330-673-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002148213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHQ017158OtherHOMETOWN
OH000000136887OtherANTHEM
OH480002970OtherMEDICARE RAILROAD
OH193565OtherUNISON
OH2922074Medicaid
OH000000136887OtherANTHEM
OH2922074Medicaid
OHW41835Medicare UPIN