Provider Demographics
NPI:1730100629
Name:SIDDALL-BENSSON, JEAN M (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:SIDDALL-BENSSON
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 1:19 STURDY ST
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-3152
Mailing Address - Country:US
Mailing Address - Phone:508-236-8348
Mailing Address - Fax:508-236-8377
Practice Address - Street 1:19 STURDY ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-3152
Practice Address - Country:US
Practice Address - Phone:508-236-8348
Practice Address - Fax:508-236-8377
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217758207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0407867OtherUHC
MA2014491Medicaid
3971511OtherCIGNA
411190OtherRIBCHIP
6000162OtherHPHC
67690OtherFALLON
MAJ26469OtherMABC
000000028123OtherBMC HEALTHNET
217758OtherTUFTS
MAJ26469OtherMABC
MAH91946Medicare UPIN