Healthcare Provider Details

I. General information

NPI: 1154558542
Provider Name (Legal Business Name): MARK G BENEDICT RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 06/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 MAIN ST
GREENFIELD IL
62044-1321
US

IV. Provider business mailing address

519 MAIN ST
GREENFIELD IL
62044-1321
US

V. Phone/Fax

Practice location:
  • Phone: 217-358-3075
  • Fax:
Mailing address:
  • Phone: 217-358-3075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041314705
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: