Provider Demographics
NPI:1487631800
Name:SAMPANG, BENJAMIN MALLARI (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MALLARI
Last Name:SAMPANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:STE 258
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:ONE MEDICAL VILLAGE DR
Practice Address - Street 2:INDEPENDENT ANESTHESIOLOGISTS. PSC
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17350207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64173503Medicaid
000000032549OtherANTHEM
OH0479601Medicaid
KY0094406Medicare ID - Type Unspecified
OH0479601Medicaid