Provider Demographics
NPI:1770672339
Name:AMY BENJAMIN
Entity type:Organization
Organization Name:AMY BENJAMIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYUS
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:662-365-0200
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:WHEELER
Mailing Address - State:MS
Mailing Address - Zip Code:38880-0095
Mailing Address - Country:US
Mailing Address - Phone:662-365-0200
Mailing Address - Fax:662-365-0199
Practice Address - Street 1:618 CR 5031
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829
Practice Address - Country:US
Practice Address - Phone:662-365-0200
Practice Address - Fax:662-365-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850588363LF0000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04071559Medicaid
C03567OtherCLINIC UPIN
MS03904817Medicaid
04071559OtherMEDICAID GROUP
MS04071559Medicaid
MS03904817Medicaid
04071559OtherMEDICAID GROUP
MS258992Medicare PIN
500002239Medicare PIN