Provider Demographics
NPI:1548752041
Name:HERITAGE NEUROLOGY PA
Entity Type:Organization
Organization Name:HERITAGE NEUROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLAJIDE
Authorized Official - Middle Name:O
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-505-5358
Mailing Address - Street 1:4849 N MESA ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5919
Mailing Address - Country:US
Mailing Address - Phone:915-351-6600
Mailing Address - Fax:915-351-6600
Practice Address - Street 1:2270 JOE BATTLE BLVD STE Q
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-2610
Practice Address - Country:US
Practice Address - Phone:915-317-1500
Practice Address - Fax:915-201-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ99562084A2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3883670-01Medicaid