Provider Demographics
NPI:1619942562
Name:BACK, BEN W (PA)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:W
Last Name:BACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-0959
Mailing Address - Country:US
Mailing Address - Phone:606-589-5514
Mailing Address - Fax:606-435-1322
Practice Address - Street 1:210 BLACK GOLD BLVD STE 106
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-2620
Practice Address - Country:US
Practice Address - Phone:606-436-0711
Practice Address - Fax:606-436-0848
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA364363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95000287Medicaid
KYS52792Medicare UPIN
KY95000287Medicaid
183942Medicare Oscar/Certification
KY00051007Medicare PIN
0984404Medicare PIN
183918Medicare Oscar/Certification
KY183947Medicare Oscar/Certification