Healthcare Provider Details

I. General information

NPI: 1376612457
Provider Name (Legal Business Name): EDWARD J BENAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225B WINTON M BLOUNT LOOP
MONTGOMERY AL
36117-3507
US

IV. Provider business mailing address

225B WINTON M BLOUNT LOOP
MONTGOMERY AL
36117-3507
US

V. Phone/Fax

Practice location:
  • Phone: 334-263-6228
  • Fax: 334-265-9136
Mailing address:
  • Phone: 334-263-6228
  • Fax: 334-265-9136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number10291
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: