Provider Demographics
NPI:1578568309
Name:LIEM, BENNY
Entity Type:Individual
Prefix:
First Name:BENNY
Middle Name:
Last Name:LIEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:
Practice Address - Street 1:1201 CAMINO DE SALUD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4517
Practice Address - Country:US
Practice Address - Phone:505-272-4946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-2402085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM009678OtherBLUE SHIELD/NM
NM32222OtherLOVELACE HEALTHPLAN
NM591570OtherAHCCCS
NM5244547OtherAETNA/PRONET
NMF1313Medicaid
NMH44726Medicare UPIN
NM1989925OtherFIRST HEALTH
NM920006565OtherMEDICARE RAILROAD