Provider Demographics
NPI:1891824553
Name:JOHN W BENTON MD PA
Entity Type:Organization
Organization Name:JOHN W BENTON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-379-2772
Mailing Address - Street 1:1600 UNIVERSITY AVENUE WEST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-379-2772
Mailing Address - Fax:651-379-2774
Practice Address - Street 1:1600 UNIVERSITY AVENUE WEST
Practice Address - Street 2:SUITE 306
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-379-2772
Practice Address - Fax:651-379-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18127207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A94037Medicare UPIN
C03464Medicare ID - Type Unspecified