Provider Demographics
NPI:1629078936
Name:BENNER, PRISCILLA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:JEAN
Last Name:BENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2779 GERYVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:PENNSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18073-2306
Mailing Address - Country:US
Mailing Address - Phone:215-679-8071
Mailing Address - Fax:215-541-4171
Practice Address - Street 1:2781 GERYVILLE PIKE
Practice Address - Street 2:
Practice Address - City:PENNSBURG
Practice Address - State:PA
Practice Address - Zip Code:18073-2306
Practice Address - Country:US
Practice Address - Phone:215-679-8071
Practice Address - Fax:215-541-4171
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017870E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0045794001OtherKEYSTONE EAST
PA090232OtherAMERIHEALTH
PA090232OtherBLUE SHIELD
PA50002697OtherCAPITAL BLUE CROSS
PA0006280500004Medicaid
PA0045794001OtherINDEPENDENCE BLUE CROSS
PA0045794001OtherAETNA
PA1026082OtherKEYSTONE MERCY
PAP3152581OtherOXFORD
PA610383300OtherBLACK LUNG
PA0045794001OtherPERSONAL CHOICE
PA1026082OtherKEYSTONE MERCY
PA0045794001OtherKEYSTONE EAST
PA610383300OtherBLACK LUNG