Provider Demographics
NPI:1720041890
Name:CROSSROADS MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:CROSSROADS MEDICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:I
Authorized Official - Last Name:BENESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-998-9955
Mailing Address - Street 1:2700 QUARRY LAKE DRIVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-0000
Mailing Address - Country:US
Mailing Address - Phone:410-998-9955
Mailing Address - Fax:410-998-9961
Practice Address - Street 1:2700 QUARRY LAKE DRIVE
Practice Address - Street 2:SUITE 350
Practice Address - City:BALITMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-0000
Practice Address - Country:US
Practice Address - Phone:410-998-9955
Practice Address - Fax:410-998-9961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKP27Medicare ID - Type Unspecified