Healthcare Provider Details

I. General information

NPI: 1952776429
Provider Name (Legal Business Name): SEBASTIEN BENALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVENUE BOSTON CHILDREN'S HOSPITAL/RADIOLOGY
BOSTON MA
02115
US

IV. Provider business mailing address

199 MASSACHUSETTS AVE #412
BOSTON MA
02115-3051
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6936
  • Fax: 617-730-0549
Mailing address:
  • Phone: 617-355-6936
  • Fax: 617-730-0549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number263115
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: