MEDICARE: FRED A BENJAMIN IV CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN0000085124	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063404036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRED A BENJAMIN IV CRNA

Provider Business Mailing Address
First Line	:	70 STATE ROUTE 420
Second Line	:
City	:	HUMBOLDT
State	:	TN
Zip	:	38343-5619
Country	:	US
Telephone Number	:	731-824-1939
Fax Number	:

Provider Business Practice Location Address
First Line	:	36 BRENTSHIRE SQ
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-2245
Country	:	US
Telephone Number	:	731-664-1717
Fax Number	:	731-664-7114

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	07/08/2007

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