Healthcare Provider Details

I. General information

NPI: 1245929652
Provider Name (Legal Business Name): BENJAMIN E MOREHEAD AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 BANDANA BLVD E STE 100
SAINT PAUL MN
55108-5109
US

IV. Provider business mailing address

736 MINNEHAHA AVE W
SAINT PAUL MN
55104-1624
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-9700
  • Fax:
Mailing address:
  • Phone: 605-201-3853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number528360
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: