Provider Demographics
NPI:1669767729
Name:RASE, BENJAMIN LLOYD (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:LLOYD
Last Name:RASE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 ELLIS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8811
Mailing Address - Country:US
Mailing Address - Phone:406-587-8631
Mailing Address - Fax:406-587-1343
Practice Address - Street 1:1648 ELLIS ST STE 201
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-8811
Practice Address - Country:US
Practice Address - Phone:406-587-8631
Practice Address - Fax:406-587-1343
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075286A2085R0202X
IN11016076A390200000X
MTMED-PHYS-LIC-875582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01719342Medicare PIN
IN959090034Medicare PIN