Healthcare Provider Details

I. General information

NPI: 1053409508
Provider Name (Legal Business Name): MARILEE BENSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 E CHESTNUT ST
LOUISVILLE KY
40202-1821
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-7661
  • Fax: 502-629-5309
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number24378
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: