Provider Demographics
NPI:1821279787
Name:BENJAMIN MEDICAL ASSOCIATES, FORNEY. PA
Entity Type:Organization
Organization Name:BENJAMIN MEDICAL ASSOCIATES, FORNEY. PA
Other - Org Name:BMA FORNEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:9725-522-2621
Mailing Address - Street 1:1611 N BELT LINE RD
Mailing Address - Street 2:STE A
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-1722
Mailing Address - Country:US
Mailing Address - Phone:972-613-1000
Mailing Address - Fax:972-613-4232
Practice Address - Street 1:124 E US HIGHWAY 80
Practice Address - Street 2:STE 104
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-8612
Practice Address - Country:US
Practice Address - Phone:972-552-2621
Practice Address - Fax:972-552-2620
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENJAMIN MEDICAL ASSOCIATES, FORNEY. PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-20
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL 2800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182616601Medicaid
TX00230YMedicare PIN