Provider Demographics
NPI:1932299237
Name:BENCKENDORF, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BENCKENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03570-2006
Mailing Address - Country:US
Mailing Address - Phone:603-752-2040
Mailing Address - Fax:603-752-7797
Practice Address - Street 1:59 PAGE HILL RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NH
Practice Address - Zip Code:03570-3531
Practice Address - Country:US
Practice Address - Phone:603-752-2900
Practice Address - Fax:603-752-3727
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-060813207Q00000X, 207QG0300X
NH15334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060813Medicaid
NH3071951Medicaid
ILC43300Medicare UPIN
IL036060813Medicaid
IL809860Medicare ID - Type UnspecifiedGROUP #
NH3071951Medicaid