Provider Demographics
NPI:1639743180
Name:OLIVER, BENJAMIN ISAAC
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ISAAC
Last Name:OLIVER
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:PRISMA HEALTH MEDICAL GROUP FAMILY MEDICINE CENTER
Mailing Address - Street 2:3209 COLONIAL DRIVE
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-6113
Mailing Address - Fax:803-434-8478
Practice Address - Street 1:PRISMA HEALTH MEDICAL GROUP FAMILY MEDICINE CENTER
Practice Address - Street 2:3209 COLONIAL DRIVE
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6113
Practice Address - Fax:803-434-8478
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL86291207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program