Healthcare Provider Details

I. General information

NPI: 1083810170
Provider Name (Legal Business Name): GEORGE ROBERT BENELLI R.T, RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

9901 SW 165TH TER
MIAMI FL
33157-3264
US

V. Phone/Fax

Practice location:
  • Phone: 305-325-5916
  • Fax:
Mailing address:
  • Phone: 786-427-4287
  • Fax: 305-325-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number57646
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: