Provider Demographics
NPI:1609948009
Name:BOULEVARD EAST FAMILY AND OCCUPATIONAL MEDICINE INC
Entity Type:Organization
Organization Name:BOULEVARD EAST FAMILY AND OCCUPATIONAL MEDICINE INC
Other - Org Name:MOSES BENAVIDES MD
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:BENAIAH
Authorized Official - Last Name:BENAVIDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-318-1185
Mailing Address - Street 1:1443 W MORRIS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813
Mailing Address - Country:US
Mailing Address - Phone:423-318-1185
Mailing Address - Fax:423-318-1015
Practice Address - Street 1:222 BOWMAN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-3856
Practice Address - Country:US
Practice Address - Phone:423-318-1185
Practice Address - Fax:423-318-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
TNMD0000040290261QC1500X, 261QC1800X, 261QM1103X, 261QP2300X, 261QU0200X, 261QX0100X
TNDS0000007577261QD0000X
TNMD 0000040290261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM1103XAmbulatory Health Care FacilitiesClinic/CenterMilitary Ambulatory Procedure Visits Operational (Transportable)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNBB9370189OtherDEA