Provider Demographics
NPI:1497827414
Name:IGOR BENENSON M.D.,D.O.,P.C
Entity Type:Organization
Organization Name:IGOR BENENSON M.D.,D.O.,P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-969-0300
Mailing Address - Street 1:9892 BUSTLETON AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2184
Mailing Address - Country:US
Mailing Address - Phone:215-969-0300
Mailing Address - Fax:
Practice Address - Street 1:9892 BUSTLETON AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2184
Practice Address - Country:US
Practice Address - Phone:215-969-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA076601SK4OtherMEDICARE ID TYPE-GROUP
PA1009797730001Medicaid
PA076601SK4OtherMEDICARE ID TYPE-GROUP
PA076601SK4Medicare PIN
PA=========OtherTAX ID