Provider Demographics
NPI:1619938024
Name:MID ATLANTIC HEALTH SPECIALISTS PC
Entity Type:Organization
Organization Name:MID ATLANTIC HEALTH SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BENISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-236-2947
Mailing Address - Street 1:103 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2277
Mailing Address - Country:US
Mailing Address - Phone:276-236-2947
Mailing Address - Fax:
Practice Address - Street 1:103 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2277
Practice Address - Country:US
Practice Address - Phone:276-236-2947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057515207Q00000X
VA0101041026207RG0100X
VA0110001464363A00000X
VA0024103947363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890249MMedicaid
VA226464OtherBCBS
VAC06123Medicare PIN