Healthcare Provider Details

I. General information

NPI: 1669819272
Provider Name (Legal Business Name): BENJAMIN LISS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N 15TH ST DEPARTMENT OF EMERGENCY MEDICINE
PHILADELPHIA PA
19102-1101
US

IV. Provider business mailing address

245 N 15TH ST DEPARTMENT OF EMERGENCY MEDICINE
PHILADELPHIA PA
19102-1101
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-2365
  • Fax:
Mailing address:
  • Phone: 215-762-2365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT204504
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: