Provider Demographics
NPI:1518939305
Name:IRISH-BENJAMIN, KATHY ANN CAROL (MD)
Entity Type:Individual
Prefix:
First Name:KATHY ANN
Middle Name:CAROL
Last Name:IRISH-BENJAMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 BLACK RIVER BLVD N
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2427
Mailing Address - Country:US
Mailing Address - Phone:315-337-3770
Mailing Address - Fax:
Practice Address - Street 1:1801 BLACK RIVER BLVD N
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2427
Practice Address - Country:US
Practice Address - Phone:315-337-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172945208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01402937Medicaid
NYG08289Medicare UPIN