Provider Demographics
NPI:1851762215
Name:BENUSA, MICHAEL (IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BENUSA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376
Mailing Address - Country:US
Mailing Address - Phone:910-853-1290
Mailing Address - Fax:
Practice Address - Street 1:226 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-5410
Practice Address - Country:US
Practice Address - Phone:910-853-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic