Provider Demographics
NPI:1720052251
Name:DORSAM, BENEDICT RICHARD (PA)
Entity Type:Individual
Prefix:
First Name:BENEDICT
Middle Name:RICHARD
Last Name:DORSAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2649 SCHOENERSVILLE RD
Mailing Address - Street 2:STE 205
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017
Mailing Address - Country:US
Mailing Address - Phone:610-866-2233
Mailing Address - Fax:610-882-3474
Practice Address - Street 1:2649 SCHOENERSVILLE RD
Practice Address - Street 2:STE 301
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017
Practice Address - Country:US
Practice Address - Phone:610-866-2233
Practice Address - Fax:610-882-3474
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
095075F42Medicare ID - Type Unspecified
Q53648Medicare UPIN