Healthcare Provider Details

I. General information

NPI: 1841357399
Provider Name (Legal Business Name): CHARLES I BENJAMIN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 20TH ST S
FARGO ND
58104-5917
US

IV. Provider business mailing address

3280 20TH ST S
FARGO ND
58104-5917
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-7408
  • Fax: 701-235-2099
Mailing address:
  • Phone: 701-293-7408
  • Fax: 701-235-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier13742
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier292L3BE
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMN BLUE SHIELD
# 3
Identifier06334001
Identifier TypeOTHER
Identifier StateND
Identifier IssuerND BLUE SHIELD

VIII. Authorized Official

Name: MARGARET GILBERTSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 701-499-4807