Provider Demographics
NPI:1619968591
Name:SOULE, BENJAMIN PETERSEN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:PETERSEN
Last Name:SOULE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 N 39TH ST
Mailing Address - Street 2:MUTCH BLDG. 5TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-2775
Mailing Address - Fax:215-662-3440
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:MUTCH BLDG. 5TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-2775
Practice Address - Fax:215-662-3440
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD440070207R00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415096100Medicaid
PAMD440070OtherMEDICAL LICENSE
MD415096100Medicaid
DC131265Medicare PIN