Provider Demographics
NPI:1710921986
Name:VERDINE, BENJAMIN W (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:W
Last Name:VERDINE
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 1:901 PATIENTS FIRST DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-239-7727
Mailing Address - Fax:636-239-5021
Practice Address - Street 1:901 PATIENTS FIRST DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4700
Practice Address - Country:US
Practice Address - Phone:636-239-7727
Practice Address - Fax:636-239-5021
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010199972086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01135271OtherRAILROAD MEDICARE
P00326905OtherRAILROAD MEDICARE
MO207465006Medicaid
MO143870005Medicare PIN
936152943Medicare PIN
P00326905OtherRAILROAD MEDICARE
MO207465006Medicaid