Provider Demographics
NPI:1629833298
Name:FRAYSUR, BENJAMIN RUSSELL
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RUSSELL
Last Name:FRAYSUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 LODGE DR APT I
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35216-6299
Mailing Address - Country:US
Mailing Address - Phone:601-692-3657
Mailing Address - Fax:
Practice Address - Street 1:3704 LODGE DR APT I
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35216-6299
Practice Address - Country:US
Practice Address - Phone:601-692-3657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program