Healthcare Provider Details

I. General information

NPI: 1730360678
Provider Name (Legal Business Name): BENJMIN MICHAEL FOX ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY PLZ # MS 7000
CAPE GIRARDEAU MO
63701-4710
US

IV. Provider business mailing address

1966 DELWIN ST APT 4
CAPE GIRARDEAU MO
63701-2470
US

V. Phone/Fax

Practice location:
  • Phone: 573-999-6217
  • Fax:
Mailing address:
  • Phone: 573-999-6217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2011040138
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: