Provider Demographics
NPI:1992836134
Name:MAX BENZAQUEN M D PC
Entity Type:Organization
Organization Name:MAX BENZAQUEN M D PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:MARLENE
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-878-8744
Mailing Address - Street 1:224 S WOODS MILL RD
Mailing Address - Street 2:SUITE 290 SOUTH
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3451
Mailing Address - Country:US
Mailing Address - Phone:314-878-8744
Mailing Address - Fax:314-878-2234
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:SUITE 290 SOUTH
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3451
Practice Address - Country:US
Practice Address - Phone:314-878-8744
Practice Address - Fax:314-878-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100507174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10730OtherBLUE CROSS
F45886Medicare UPIN