Healthcare Provider Details

I. General information

NPI: 1023014487
Provider Name (Legal Business Name): BERNARD J BENEDETTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BORTHWICK AVE STE 308
PORTSMOUTH NH
03801-7112
US

IV. Provider business mailing address

104 ENDICOTT ST SUITE 200
DANVERS MA
01923-3623
US

V. Phone/Fax

Practice location:
  • Phone: 603-431-5242
  • Fax: 603-431-5091
Mailing address:
  • Phone: 978-882-6868
  • Fax: 978-882-6828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number236697
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD11776
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number11776
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number19048
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: