Healthcare Provider Details

I. General information

NPI: 1003557307
Provider Name (Legal Business Name): BENJAMIN CHARLES HERSCH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2022
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 GRAND AVE STE 101
GLENWOOD SPRINGS CO
81601-4181
US

IV. Provider business mailing address

2425 GRAND AVE STE 101
GLENWOOD SPRINGS CO
81601-4181
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-1007
  • Fax: 970-985-7812
Mailing address:
  • Phone: 970-945-1007
  • Fax: 970-985-7812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA7302
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: