Provider Demographics
NPI:1811475403
Name:PUSHARD, BENJAMIN PHILIP (ATC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:PHILIP
Last Name:PUSHARD
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1548
Mailing Address - Country:US
Mailing Address - Phone:207-989-4401
Mailing Address - Fax:
Practice Address - Street 1:270 WILSON ST
Practice Address - Street 2:SAME
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1548
Practice Address - Country:US
Practice Address - Phone:207-989-4401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR2036111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty