Provider Demographics
NPI:1811925001
Name:BENINK, ERIC H (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:H
Last Name:BENINK
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 1:877 JEFFERSON AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-8336
Mailing Address - Fax:
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-545-8699
Practice Address - Fax:901-545-8996
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077518207PE0004X
TN52241207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL834340OtherMEDICARE GROUP PTAN
IL553180035OtherMEDICARE INDIVIDUAL PTAN
IL834340023OtherMEDICARE INDIVIDUAL PTAN
IL553180OtherMEDICARE GROUP PTAN
IL36077518Medicaid
IL834340023OtherMEDICARE INDIVIDUAL PTAN
ILL79863Medicare ID - Type Unspecified