Healthcare Provider Details

I. General information

NPI: 1386632586
Provider Name (Legal Business Name): TIMOTHY FRED BENGE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MAIN ST
DANVILLE IN
46122-1948
US

IV. Provider business mailing address

2880 COMMONWEALTH DR UNIT 418
SPRING HILL TN
37174-3177
US

V. Phone/Fax

Practice location:
  • Phone: 317-745-4451
  • Fax:
Mailing address:
  • Phone: 615-614-1708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3158
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number103774
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: