Healthcare Provider Details

I. General information

NPI: 1134624570
Provider Name (Legal Business Name): BENJAMIN MARCUS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 32ND AVE S
FARGO ND
58103-6132
US

IV. Provider business mailing address

1621 34TH ST S APT 18
FARGO ND
58103-8416
US

V. Phone/Fax

Practice location:
  • Phone: 701-231-8011
  • Fax:
Mailing address:
  • Phone: 845-705-7864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number773-17
License Number StateND

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: